LIBRARY OF. CONGRESS, 

o v.lk^ 

Chap....V\M Copyright No..._...-_ 

Sliell..._a.4_^ b 



UNITED STATES OF AMERICA. 



DISEASES OF THE EYE 



SWANZY 



A HANDBOOK 



DISEASES OF THE EYE 



AND THEIR 



TREATMENT 



HENRY R. SWANZY, A.M., M.B., F.R.C.S.I. 

EXAMINER IN OPHTHALMOLOGY TO THE UNIVERSITY OF DUBLIN; SURGEON TO THE NATIONAL 

EYE AND EAR INFIRMARY, AND OPHTHALMIC SURGEON TO THE 

ADELAIDE HOSPITAL, DUBLIN , 



SIXTH EDITION 
WITH ILLUSTRATIONS 






f'Ub 181897 J^^ 

PHILADELPHIA 




P. BLAKISTON, SON & CO. 

IOI2 WALNUT STREET 

1897 






S^L 



Copyright, 1897, by P. Blakiston, Son & Co. 



PRESS OF WM. F. FELL & CO.. 

1220-24 SANSOM ST., 

PHILADELPHIA. 



I DEDICATE THIS BOOK 

TO 

THEODOR LEBER, 

PROFESSOR AT THE UNIVERSITY OF HEIDELBERG, 

AS A MARK OF 

MY ADMIRATION FOR HIS EMINENT SERVICES 

TO OPHTHALMOLOGY, 

AND OF 
MY SINCERE REGARD. 



PREFACE TO THE SIXTH EDITION 



The fifth edition of this book was issued in January, 1895, 
and has been for some months out of print. 

In this edition the pages in the first chapter of former 
editions on ** Some Elementary Optics " have been omitted 
to make room in the book for other matter. After all, it 
may be reasonably expected that the student will bring with 
him to the study of eye disease, not only a good knowledge 
of the anatomy and physiology of the eye, but also that 
acquaintance with optical laws which is required for the 
proper understanding of the refraction and accommodation of 
the eye, and of the theory of the ophthalmoscope. 

The other chief alterations and improvements that have 
been made are in chapters xvii and xix. In the former 
chapter, more attention has been given to the ocular diseases 
and symptoms liable to accompany diffuse organic brain dis- 
ease and diseases of the spinal cord, and an account of the 
functional derangements of vision has been introduced. In 
chapter xix the tumors of the orbit have been treated of at 



viii PREFACE TO THE SIXTH EDITION. 

greater length, as well as their complication with affections of 
neighboring cavities. 

All through the book a careful revision has been carried 
out, and many minor alterations effected. 

23, Merrion Square, 
March, i8gy. 



PREFACE TO THE FOURTH EDITION. 



The third edition of this book was pubHshed in October, 
1890, and I am gratified that the work continues to find favor, 
not only with students, for whom it is mainly intended, but 
also with practitioners. 

The book has now again been revised throughout, and 
brought up to date. 

In an appendix, Holmgren's method for testing the color- 
sense has been described in greater detail than before. 

Some new illustrations have been added. 

The great difficulty of an author in the preparation of a 
book like this consists in "saying not all he might, but all 
he ought." It is his duty to give a succinct and practical 
account of his subject in its most modern aspect, without 
weighting his pages with excessive detail and prolonged dis- 
cussion. This has been my aim. For deeper and wider 
information, larger handbooks and original monographs must 
be consulted. 

23, Merrion Square, 
October, i8g2. 



CONTENTS. 



CHAPTER I. 

PAGE 

Numbering of Trial-lenses and Spectacle Glasses — Normal Refraction and 
Accommodation — The Meter Angle — The Angle Gamma — The Sense 
of Sight (Light-sense, Color-sense, Form-sensej — The Field of Vision, 17 

CHAPTER II. 

ABNORMAL REFRACTION AND ACCOMMODATION. 

Hypermetropia — Correction of Hypermetropia — Amplitude of Accommoda- 
tion in Hypermetropia — Angle Gamma in Hypermetropia — Cramp of 
Ciliar}' Muscle in Hypermetropia — Accommodative Asthenopia in Hyper- 
metropia — Internal Strabismus in Hypermetropia — The Prescribing of 
Spectacles in Hypermetropia, 39 

Myopia — Determination of Degree of Myopia — Amplitude of Accommoda- 
tion in Myopia — Angle Gamma in Myopia — Complications of Progressive 
Myopia — Management of Myopia — Operative Cure of i».Iyopia — The 
Prescribing of Spectacles in Myopia, 45 

Astigmatism — Symptoms of Astigmatism — Estimation of Degree of, and 
Correction of Astigmatism —The Astigmometer — Lental Astigmatism — 
Irregular Astigmatism, 56 

Anisometropia, 70 

Anomalies of Accommodation — Presbyopia — Paralysis of Accommodation — 

Cramp of Accommodation, 71 

CHAPTER III. 

THE OPHTHALMOSCOPE. 

Why Necessar}- — Helmholtz's Ophthalmoscope — Modern Ophthalmoscope 

— Direct Method — Indirect Method, 77 

Estimation of the Refraction by Aid of the Ophthalmoscope — Direct Method 

— Retinoscopy, 84 

Focal Illumination, 99 

The Normal Fundus Oculi as seen with the Ophthalmoscope — The Optic 
Papilla — The Retina — The Macula Lutea — The General Fundus Oculi 
— The Retinal Vessels, 99 

CHAPTER IV. 

DISEASES OF THE CONJUNCTIVA.. 

H}'peremia — Conjunctivitis — Catarrhal, or Simple Acute Conjunctivitis — Fol- 
licular Conjunctivitis — Spring Catarrh — Trachoma, Granular Conjuncti- 

xi 



xii CONTENTS. 

PAGE 

vitis, or Granular Ophthalmia — Acute Trachoma or Granular Ophthal- 
mia — Chronic Trachoma or Granular Ophthalmia — Lymphoma of the 
Conjunctiva — Acute Blennorrhea of the Conjunctiva, or Purulent Oph- 
thalmia — Croupous Conjunctivitis — Diphtheric Conjunctivitis — Con- 
junctival Complication of Small-pox — Amyloid Degeneration — Tuber- 
cular Disease of the Conjunctiva — Lupus — Pemphigus — Xerophthalmos 
— Pterygium — Pinguecula — Subconjunctival Ecchymosis — Nevus — 
Polypus — Dermoid Tumors — Lipoma — Syphilitic Disease of the Con- 
junctiva — Papilloma, or Papillary Fibroma — Epithelioma — Sarcoma — 
Simple Cysts — Subconjunctival Cysticercus — Lithiasis — Uric iVcid De- 
posits — Injuries of the Conjunctiva, 105 

CHAPTER V. 

PHLYCTENULAR, OR STRUMOUS, CONJUNCTIVITIS AND KERATITIS. 

Solitary, or Simple, Phlyctenula of the Conjunctiva — Multiple, or Miliary, 
Phlyctenula of the Conjunctiva — Modes of Secondary Corneal Affec- 
tion — Primary Phlyctenular Keratitis — Different Forms of Same — Symp- 
toms of Phlyctenular Keratitis — Causes of Phlyctenular Ophthalmia — 
Treatment, , 153 

CHAPTER VL 

DISEASES OF THE CORNEA. 

Inflammations of the Cornea — [a] Ulcerative Inflammations of the Cornea 
— Simple Ulcer — Deep Ulcer — Ulcus Serpens — Rodent Ulcer — Mar- 
ginal Ring Ulcer — Absoiption Ulcer — Neuroparalytic Keratitis — In- 
fantile Ulceration of the Cornea with Xerosis of the Conjunctiva — 
Herpes — Filamentous Keratitis — Bullous Keratitis — Dendriform Kera- 
titis, 162 

[d) Nonulcerative Inflammations of the Cornea — Abscess — Diffuse 
Interstitial Keratitis — Keratitis Punctata — Scleotizing Opacity — Ribbon- 
like Keratitis, 186 

Ectasies of the Cornea — Staphyloma Corneae — Conic Cornea, 194 

Tumors of the Cornea, 202 

Injuries of the Cornea — Foreign Bodies — Losses of Substance, 203 

Opacities of the Cornea — Nebula, Macula, Leukoma — Arcus Senilis, . . . 205 
Pigmentation of the Cornea, 209 

CHAPTER VIL 

DISEASES OF THE EYELIDS. 

Eczema — Herpes Zoster Ophthalmicus — Primary Syphilitic Sores — Secondary 
Syphilitic Sores — Tertiaiy Syphilitic Affection — Vaccine Vesicles — 
Rodent Ulcer — Marginal Ble[)haritis (Ophthalmia Tarsi)— Phtheiriasis 
Ciliorum — Hordeolum fStye) — Chalazion (Meibomian Cyst, Tarsal 
Tumor) — Milium — Molluscum — Nevi — Xanthelasma — Chromidrosis 
— Epithelioma, Sarcoma, Adenoma, and Lupus — Clonic Cramp of the 
Orbicularis Muscle — Blepharospasm — Ptosis — Operations for its Cure 
— Lagophthalmos — Symblepharon — Blepharophimosis — Canthoplastic 
Operation — Distichiasis and Trichiasis — Operations for their Cure — 



CONTEXTS. 



Entropion — Operations for its Cure — Spastic Entropion — Senile 
Entropion — Operations for its Cure — Ectropion — Operations for its 
Cure — Ankyloblepharon — The Restoration of an Eyelid — Injuries — 
Ecch}Tnosis — Epicanthus — Congenital Coloboma, 210 

CHAPTER VIII. 

DISEASES OF THE L.\CRIMAL APPARATUS. 

Malposition of the Punctum Lacrimale — Stenosis and Occlusion of the 
Punctum Lacrimale — Obstruction of the Canaliculus — Stricture of the 
Xasal Duct — Blennorrhea of the Lacrimal Sac — Acute Dacryocystitis 
— Dacryoadenitis — Hypertrophy of the Lacrimal Gland, 260 

CHAPTER IX. 

DISEASES OF THE SCLEROTIC. 

Inflammations of the Sclerotic — Episcleritis — Periodic Transient Episcleritis, 
or Hot Eye — Deep Scleritis — Injuries of the Sclerotic — Tumors of the 
Sclerotic — Pigment Spots, 271 

CHAPTER X. 

DISEASES OF THE UVEAL TRACT. 

Iritis — Sj-mptoms — Syphilitic Iritis — Rheumatic Iritis — Gonorrheal Iritis — 

Keratitis Punctata — Causes — Prognosis — Treatment, 279 

Injuries of the Iris — Punctured Wounds — Foreign Bodies — Iridodialysis — 
Retroflection — Rupture of the Sphincter Iridis — Traumatic Aniridia — 
Anteversion — Travunatic Mydriasis, 289 

X'ew Growths of the Iris — Cysts — Granuloma — Tubercle (Milian,-, Solitary) 

— .Sarcoma — Ophthalmia X'odosa, 292 

Congenital Malformations of the Iris — Heterophthalmos — Corectopia — 

Polycoria — Persistent Pupillary Membrane — Coloboma Irideremia, . . 295 

Operations on the Iris — Iridectomy — Iridotomy, 296 

Cyclitis— Plastic Cyclitis — Serous Cyclitis — Purulent Cyclitis — Injuries of 

the Ciliary- Body — X*ew Growths of the Ciliary Body, 299 

Choroiditis — Disseminated Choroiditis — Syphilitic Choroidoretinitis — Central 
Senile Gutlate Choroiditis — Central Choroiditis — Central Senile Atrophy 
of the Choroid — Purulent Choroiditis — Posterior Sclerochoroiditis — 
Detachment of the Choroid, 302 

Injuries of the Choroid — Eoreign Bodies — Incised Wounds — Rupture — 
Xew Growths of the Choroid — Sarcoma — Carcinoma — Tubercle — Sar- 
coma Carcinomatosum — Myosarcoma — Osteosarcoma, 309 

Congenital Defects of the Choroid — Coloboma — Albinism, 313 

Sympathetic Ophthalmitis 314 

CHAPTER XI. 

MOTIONS OF THE PUPIL IN HEALTH AND DISEASE. 

The Size of the Pupil in Health — Contraction of the Pupil — Dilatation of 

the Pupil, 326 

The Action of the Mydriatics and Miotics on the Pupil, ^^2 

The Size of the Pupil in Disease — Miosis — Mydriasis, ^2i3 



xiv CONTENTS. 

CHAPTER XIL 

GLAUCOMA. 

PAGE 

Primary Glaucoma — Chronic, or Non-inflammatory, Glaucoma — Acute, or 
Inflammatory, Glaucoma — Glaucoma Fulminans — Subacute Glaucoma 

— Etiology — Pathology — Treatment, 338 

Secondary Glaucoma — Hemorrhagic Glaucoma, 360 

Congenital Hydrophthalmia, 362 

CHAPTER XIII. 

DISEASES OF THE CRYSTALLINE LENS. 

Complete Cataracts — Senile Cataract — Progress, Pathogenesis, and Etiology 

— Treatment, 363 

Complete Cataract of Young People — Diabetic Cataract — Complete Con- 
genital Cataract — Black Cataract, 371 

Partial Cataracts — Central Lental Cataract — Zonular, or Lamellar, Cataract 
— Anterior Polar, or Pyramidal, Cataract — Fusiform, or Spindle- 
shaped, Cataract, 373 

Secondary Cataract — Posterior Polar Cataract — Total Secondary Cataract, . 375 

Capsular Cataract, 376 

Traumatic Cataract, 376 

Operations for Cataract — Extraction of Cataract — Linear Extraction — The 
Modified Peripheral Linear Extraction — The Three Millimeter Flap- 
operation — Cataract Extraction without Iridectomy, 379 

Discission, or Dilaceration — Suction Operation — Secondary Cataract and its 

Operation — Capsulotomy — Iridotomy, 405 

Dislocation of the Crystalline Lens — Lenticonus — Aphakia, 410 

CHAPTER XIV. 

DISEASES OF THE VITREOUS HUMOR. 

Purulent Inflammation — Other Inflammatory Affections — Opacities — Musc?e 
Volitantes — Fluidity (Synchysis) — Synchysis Scintillans — Foreign 
Bodies — Cysticercus — Blood-vessels — Persistent Hyaloid Artery — 
Detachment, 414 

CHAPTER XV. 

DISEASES OF THE RETINA. 

Alterations in Vascularity — Hyperemia — Anemia, 425 

Inflammation of the Retina, or Retinitis — Syphilitic — Hemorrhagic — 
Albuminuric — Diabetic — Leuksemica — Retinitis Punctata Albescens — 
Development of Connective Tissue, or Retinitis Proliferans — Retinitis 

Circinata — Purulent Retinitis, 425 

Atrophy of the Retina — Retinitis Pigmentosa, 435 

Diseases of the Retinal Vessels — Apoplexy of the Retina — Embolism of the 
Central Artery — Thrombosis of the Central Artery — Thrombosis of the 
Central Vein — Aneurysm of the Central Artery — Sclerosis of the 
Retinal Vessels (Perivasculitis) — (^uinin Amaurosis, 436 



CONTENTS. XV 

PAGE 

Injury of the Retina by Strong Light — Sunlight — Snow-blindness — Effect of 

Electric Light on the Eyes, 443 

Tumor of the Retina — Glioma, 446 

Parasitic Disease of the Retina — Cysticercus, 448 

Detachment of the Retina, 448 

Traumatic Affections of the Retina — Traumatic Anesthesia — Commotio 

Retinae, or Traumatic Edema of the Retina, 453 



CHAPTER XVI. 

DISEASES OF THE OPTIC NERVE. 

Optic Neuritis (Papillitis), due to: — Cerebral Tumors — Tubercular Men- 
ingitis—Acute Myelitis — Hydrocephalus — Tumors of the Orbit — In- 
flammatory Processes in the Orbit — Exposure to Cold — Suppression of 
Menstruation — Chlorosis — Syphilis — Rheumatism — Lead-poisoning — 
Peripheral Neuritis —Multiple Sclerosis— and to Hereditary and Con- 
genital Predisposition, 455 

Chronic Retrobulbar Neuritis, or Central Amblyopia (Toxic Amblyopia) — 
Optic Neuritis Associated with Persistent Dropping of Watery Fluid 
from the Nostril, 462 

Atrophy of the Optic Nerve, due to: — Optic Neuritis — Pressure — Embolism 
of the Central Artery of the Retina — Syphilitic Retinitis, Retinitis 
Pigmentosa, Choroidoretinitis, and to Disease of the Spinal Cord 
(Spinal Amaurosis) — Optic Atrophy as a purely Local Disease, . . . 467 

Tumors of the Optic Nerve — Hyaline, or Colloid, Outgrowths — Injuries of 
the Optic Nerve — Amblyopia due to Hemorrhages from the Stomach, 
Bowels, or Uterus — Glycosuric Amblyopia, 470 



CHAPTER XVII. 
PART I. 

OCULAR DISEASES AND SYMPTOMS LIABLE TO ACCOMPANY FOCAL DISEASE OF 

THE BRAIN. 

Hemianopia — Arrangement of the Cortical Visual Centers, their Relations 
to the Retina, and the Course of the Optic Fibers between these two 
points — Localization of the Lesion in Hemianopia — Alexia, or Word- 
blindness — Visual Aphasia — Dyslexia — Amnesic Color-blindness — 
Visual Hallucinations — Mind-blindness, or Optic Amnesia, 475 



PART II. 

OCULAR DISEASES AND SYMPTOMS LIABLE TO ACCOMPANY DIFFUSE ORGANIC 
DISEASES OF THE BRAIN. 

Disseminated Sclerosis of the Brain and Spinal Cord — Diffuse Sclerosis of 
the Brain — General Paralysis of the Insane — Meningitis — Traumatic 
Meningitis — Hydrocephalus — Infantile Paralysis — Paralysis Agitans — 
Encephalopathia Saturnina — Epilepsy — Chorea, 491 



xvi CONTENTS. 

PART III. 

OCULAR DISEASES AND SYMPTOMS LIABLE TO ACCOMPANY DISEASES AND 
INJURIES OF THE SPINAL CORD. 

PAGE 

Tabes Dorsalis — Hereditary Ataxia — Myelitis — Syringomyelia, and Mor- 
van's Disease — Myotonia Congenita — Acute Ascending Paralysis — 
Injuries of the Spinal Cord, 499 

PART IV. 

NERVOUS AMBLYOPIA, OR NERVOUS ASTHENOPIA. 

Nervous Amblyopia in Neurasthenia — Nervous Amblyopia in Hysteria — 

Nervous Amblyopia in Traumatic Neurosis, 504 

PART V. 

VARIOUS FORMS. OF AMBLYOPIA. 

Transitory Hemianopia, or Scintillating Scotoma — Congenital Amblyopia — 
Reflex Amblyopia — Nyctalopia — Uremic Amblyopia — Pretended 
Amaurosis — Erythropsia, 511 

CHAPTER XVni. 

THE MOTIONS OF THE EYEBALLS, AND THEIR DERANGEMENTS. 

Actions of the Orbital Muscles —Inclination of the Vertical Meridian in the 
several Principal Positions — Muscles called into Action in the several 
Principal Positions — The Field of Fixation — Strabismus, 518 

Paralyses of the Orbital Muscles — General Symptoms — Paralysis of the Ex- 
ternal Rectus — Paralysis of the Superior Oblique — Paralysis of the In- 
ternal Rectus, Superior Rectus, Inferior Oblique, and Levator Palpe- 
brae — Ophthalmoplegic Migraine — Ophthalmoplegia Externa, or Nu- 
clear Paralysis — Fascicular Paralysis — Cerebral Paralysis of Orbital 
Muscles — The Localizing Value of Paralysis of Orbital Muscles in 
Cerebral Disease, 524 

Convergent Concomitant Strabismus — Causes — Single Vision in — Amblyopia 
of Squinting Eye — Clinical Varieties of — Measurement of — Mobility of 
Eye in — Treatment — Orthoptic Treatment — Operative Treatment — 
Tenotomy — Advancement of External Rectus — Dangers of the Strabis- 
mus Operation — Treatment Subsequent to Operation, 553 

Insufficiency of the Internal Recti, and Divergent Concomitant Strabismus 

— Muscular Asthenopia — Treatment — Operative Treatment, .... 579 

Nystagmus, 5*^5 

CHAPTER XIX. 

DISEASES OF THE ORBIT. 

Orbital Cellulitis — Periostitis of the Orbit — Caries of the Orbit — Injuries of 
the Orbit — Orbital Tumors — Implication of Neighboring Cavities — Pul- 
sating Exophthalmos — Tumors of the Lacrimal Gland — Hernia Cerebri 
— Exophthalmic Goiter — Exophthalmos, 587 



CONTENTS. xvii 

APPENDIX I. 

PAGE 

Holmgren's Method for Testing the Color-sense, 6io 



APPENDIX II. 

Regulations as to Defects of Vision which Disqualify Candidates for Admis- 
sion into the Civil, Naval, and Military Government Services, the Royal 
Irish Constabulary, and the Mercantile Marine, 613 



TO THE STUDENT. 

You should read carefully chapters i, ii, and iii, omitting 

at first the small print, either before or immediately on joining 

the Ophthalmic Hospital or Department. 

H. R. S. 



DISEASES OF THE EYE. 



CHAPTER L 

THE NUMBERING OF TRIAL-LENSES. 

The lenses in trial-cases and in spectacles are numbered 
according to the metric system. 

The lens of one meter {S9}4 inches), focal length, is called 
the dioptric unit, or the dioptry (one D), of the metric system ; 
two D, three D, four D, etc., indicate the number of meter 
lenses, or dioptrics, contained in each of these lenses ; two D 
is therefore twice as powerful a lens (its focal length only half 
as long) as one D. 

Convex lenses are indicated by the -\- sign placed before 
their number; thus, -j- 5 D ; and concave lenses by the — sign; 
thus, — 5 D. 

If it be required to ascertain the focal length of a given 
lens, divide 100 (i meter = 100 centimeters) by the number 
of the lens, and the answer will give the focal length in centi- 
meters. For example, the focal length often D is '^-^-^ = 10 
cm. 

If the focal leno-th of the lens be known, and it be desired 
to ascertain its dioptric number, we find it by dividing 100 
cm. by the focal length. For example, if the focal length be 
33 cm., then ig^o = 30. 

2 17 



i8 DISEASES OF THE EYE. 



THE POWERS OF NORMAL REFRACTION AND 
ACCOMMODATION OF THE EYE. 

The eye is a dark chamber containing a series of convex 
refracting surfaces ; namely, the cornea, and the anterior and 
posterior surfaces of the crystalline lens ; and certain intra- 
ocular or dioptric media ; namely, the aqueous humor, the 
substance of the crystalline lens, and the vitreous humor. 
By aid of this apparatus, which is called the dioptric system 
of the eye, distinct inverted images of external objects are 
formed on the retina. 

The refracting media are centered on the optic axis (0 A, 




Fig. I. 



Fig. i), a Hne which, passing through the optic center (^N) of 
the eye, meets the retina at a point (y^) slightly to the inner 
side of the macula lutea {^^^)- 

In treating of the eye we have to consider two sets of visual 
objects, viz.: distant objects and near objects. Distant ob- 
jects are those at six meters and more from the eye ; near 
objects are those closer to the eye than six meters. For prac- 
tical purposes the rays which pass through the pupil, coming 
from any given point of a distant object, are as good as 
parallel, their divergence being so very slight when they 
reach the eye, and we regard them as being parallel. 



ACCOMMODATION. 19 

Refraction. 

By the refraction of the eye is meant the faculty it has 
wlien at rest — /. e., without an effort of accommodation — of 
altering the direction of rays of light which pass into it, 
making parallel rays convergent, and divergent rays less 
divergent. 

In normal refraction, or emmetropia (eiifierpov, the standard ; 
u)(l>, the eye), as it is termed, parallel rays (see Fig. 2, in 
which the object from which the rays come is supposed to be 
six meters or more from the e}'e) in passing through the diop- 




FlG, 2. 

trie media are given such a convergence that they are brought 
to a focus on the layer of rods and cones of the retina, and 
form there a distinct inverted image of the point or object from 
which they come. In other words, the retina is placed at the 
principal focus of the dioptric system of the eye, which is thus 
adapted for parallel rays, and its far point (I'ide infra) is at 
infinity. 

Accommodation. 

The eye can see near objects distinctly as well as distant ob- 
jects, although the rays from any given point (<7, Fig. 3) of a 
near object reach the eye with a divergence so considerable 
that they could not be brought to a focus on the retina by the 



20 DISEASES OF THE EYE. 

unaided refraction, but would converge toward a point (their 
conjugate focus a') behind the retina, and would not form a 
distinct image on the latter, but merely a blurred image or 
circle of diffusion (at b c). It is obvious, therefore, than an 
increase of refracting power in the eye is necessary in order 
that near objects may be distinctly seen. It is this increase in 
the refracting power for the purpose of near vision which is 
called accommodation. 

The mechanism of accommodation is as follows : The 
ciliary muscle (;//, Fig. 4) contracts, thus drawing forward the 
choroid and ciliary processes, and relaxing the zonula of 
Zinn (5-), which is attached to the latter. The lens (/), which 




Fig. 3. 

was flattened by the tension of the zonula, is now free to 
assume a more spheric shape, in response to its own elas- 
ticity. The posterior surface of the lens scarcely alters in 
shape, being fixed in the patellary fossa ; but the anterior 
surface becomes more convex, thus increasing its refracting 
power. Associated with the act of accommodation is a con- 
traction of the pupil. The accompanying figure (Fig. 4) 
represents the changes which take place in accommodation, 
the dotted lines indicating the latter state. 

The Far Point and the Near Point. — It is possible for 
the eye to see objects accurately at every distance from its far 
point — /. e., its most distant point of distinct vision — (punctum 
remotum, — R.) up to a point only a few centimeters from the 



ACCOMMODATION. 21 

eye, called the near point (punctum proximum, — P.). \\> 
can find the latter by directing the patient to look at a page 
printed in small type, and by bringing it slowh' closer and 
closer to his eye, until a point is reached where he cannot dis- 
tinguish the words and letters, which become blurred. A 
point very slighth' more removed from the eye than this, 
where he can read distinctly, is the near point. Between the 
near point and the eye vision is indistinct, because no effort 
of the ciliar}- muscle can produce the amount of convexity of 
the lens required for so short a distance. 




Fig. 4. 

c. Cornea, a. Anterior chamber. /. Lens. v. Vitreous humor. ?'. Iris. z. 

Zonula of Zinn. m. Ciliary muscle. 

The Amplitude of Accommodation. — This is the amount 
of accommodative effort of which the eye is capable — /. e., the 
effort it makes in order to adapt itself from its far point (R.) 
up to its near point (P.). The amplitude of accommodation 
{a), therefore, is equal to the difference in the refracting power 
of the eye at rest ( r), and when its accommodation is exerted 
to the utmost (/), as expressed by the formula a =p — r. It 
may be represented by that convex lens placed close in front 
of the eye, which would take the place of the increased con- 



22 DISEASES OF THE EYE. 

vexity of the lens, or, in other words, which would give to 
rays coming from the nearest point of distinct vision a direction 
as if they came from the far point. The number of this lens 
expresses the amplitude of accommodation in a given eye. 

For example : If, in an emmetropic eye (^E, Fig. 5), the 
near point be situated at 20 cm., then a convex lens (Z) of 20 
cm. focal length placed close to the eye (between that point and 
the eye) would give to rays coming from the near point a direc- 
tion — i. e., would make them parallel — as though they came 
from a distant object, and this normally refracting eye would 
then be enabled, by aid of its refraction alone, to bring these 
rays to a focus on the retina. Making use of the above equa- 




FiG. 5. 

tion we find in this case — since a focal length of 20 cm. repre- 
sents a lens of five D — that a= ^ — r, but R. being situated at 
infinity, we designate it by the sign 00 ; hence, r = ^^ =^- = o ; 
therefore <2=5 — 0=^5 D.* 

* It must be observed that R. represents the distance of the far point from the 
eye, while r represents the refractive power which is added to the eye by accom- 
modation or by a lens in order to adapt it for the distance R. Hence it is evident 
that r=^ — , because the strength, or refractive power, of a lens is inversely as its 
focal length — e.g.^ a lens of the strength of four D will have a focal length of ^ 

^ . I m. 100 cm. , , T,T 1 

that of a lens of one D— ?. e., = =0.25 cm. (see above, Number- 

4 4 

ing of Trial-lenses). Similarly, / = p and a = - ; P representing the distance 
of the near point, and A. the focal length of the lens which represents the accom- 
modation. 



ACCOMMODATION. 23 

The amount of amplitude of accommodation — /.^., the num- 
ber of the lens which would represent it — is the same in every 
kind of refraction, according to the age of the individual, 
but in emmetropia alone is ^ =/» as above, because in it alone 
is r = o. 

Under the head of Anomalies of Accommodation, chapter 
ii, will be found Professor Bonders' diagram representing the 
amplitude of accommodation at different ages. 

Connection between Accommodation and Convergence 
(Relative Accommodation). — With every degree of con- 
vergence of the visual lines a certain effort of accommodation 
is associated.* Thus, if the object be situated two meters 
from the eye the visual lines converge to that point, and a 
certain effort of accommodation is made. But this connection 
between accommodation and convergence is somewhat elastic, 
for the accommodative effort may be increased or decreased, 
while the object is kept distinctly in view, and the same con- 
vergence maintained. That it may be increased is shown by 
the experiment of placing a weak concave glass before the 
eye, when it will be found that the object is still distinctly 
seen ; and if a weak convex glass be then held before the e}'e 
the object will also be clearly seen, showing that the accom- 
modative effort may be lessened without affecting vision or 
convergence. This amplitude of accommodation for a given 
point of convergence of the visual lines, found by the strongest 
concave and strongest convex glasses with which the object 
can still be distinctly seen, is called the relative amplitude of 
accommodation. That part of it which is alread}' in use, and 
is represented by the convex lens, is termed the negative part ; 
w^hile the positive part is represented by the concave lens, and 
has not been brought into play. For sustained accommoda- 

* A common center in the brain governs these motions and contraction of the 
pupil. 



24 



DISEASES OF THE EYE. 



tion at any distance it is necessary that the positive part of 
the relative ampHtude of accommodation be considerable in 
amount. 

Moreover, the convergence may be altered, while the same 
effort of accommodation is maintained, as is shown by the 
experiment of placing a weak prism with its base inward 
before one eye. In order that the object may then be seen 
singly it will be necessary for the eye before which the prism 
is placed to rotate somewhat outward ; 
and it will be found that the individual 
can do this while at the same time he 
sees the object with the same distinct- 
ness, showing that the same effort of 
accommodation has been maintained, al- 
though the angle of convergence of the 
visual axis is less than before. 

The Meter Angle. 
If the visual line [E I, Fig. 6) of an eye [E] has 
to be brought to bear on a point ( I, Fig. 6) one meter 
distant from it in the median line [M l), the angle of 
convergence {E I M) which the visual line thus 
makes with the median line is called the meter angle. 
It expresses the degree of convergence necessary for 
binocular vision at that distance, and is employed as 
the unit for expressing other degrees of convergence. 
If, for example, an object be situated )^ of a meter 
(K' ^'g- ^) f^°"^ ^^^^ ^y^' ^^^ angle of convergence 
[E Yi M) must be practically twice as large as at 
one meter: C. (convergence) = 2 meter angles. If 
the object be only i^ of a meter distant, three meter angles are required ; C. = 3 
meter angles. If the object be situated two meters from the eye, the angle of con- 
vergence will be only one-half as great as at one meter, and here C. = }4 meter 
angle ; while if the eye be directed toward a distant object {D) there will be no 
angle of convergence, and if the visual lines be divergent, the meter angle will be 
negative. 

Now the average normal emmetropic eye requires for each distance of bin- 
ocular vision as many meter angles of convergence as it requires dioptrics of 
accommodation. For a distance of one meter an effort of accommodation of one 




ACCOMMODATION. 



25 



dioptry is required, and also one meter angle of convergence ; at j^ of a meter from 
the eye two D of accommodation is required, and two meter angles ; at )^ of a 
meter from the eye three D of accommodation and three meter angles, and so on ; 
while for distant objects neither angle of convergence nor effort of accommoda- 
tion is required. 

The Angle Gamma. 

The optic axis is an imaginary line [P^ F Fig. 7) which passes through the 
center {C) oi the cornea and the posterior pole [P) of the globe — a point situated 
between the macula lutea {M) and the optic 
papilla [D). The visual line [Af O) unites 
the point of fixation (O) — the object looked 
at — with the macula lutea ; it does not coin- 
cide with the optic axis, but crosses it at the 
principal optic center (^) of the eye. The 
line of fixation [P O) joins the center of 
rotation (P) of the eye with the point of fixa- 
tion. The angle y is the angle O R P^ formed 
at the center of rotation by the optic axis and 
the line of fixation. 

The line of fixation and the visual line so 
nearly coincide that in practice we regard them 
as identical ; and hence, in practice, the angle 
y is the angle OKP' . It should not be con- 
founded, as is often the case, with the angle 
alpha, which is the angle OKC formed at the 
nodal point by the visual line and the major 
axis {^C' K) of the corneal ellipse. This axis 
rarely passes through the center of the cornea ; 
but, as it never lies far from the latter, the 
diff"erence in dimension between the two angles 
is very slight. 

In order to measure the angle 7, the eye is 
placed at the perimeter as for an examination 
of its field of vision. By means of the corneal 
reflection of a candle flame, which latter is 
moved along the arc of the perimeter, the 
center of the cornea is found. The position of 
the flame at the perimeter then gives the angle } , 
is five degrees. 




P^IG. 7. 
The average size of the angle } 



26 DISEASES OF THE EYE. 

THE SENSE OF SIGHT. 

The sense of sight consists of three visual preceptions or 
sub-senses — namely, the light-sense, the color-sense, and 
the form -sense (see Chap. xvii). 

The light-sense is the power the retina, or the visual 
center, has of perceiving gradations in the intensity of illumina- 
tion. A convenient clinical method of testing the light-sense 
is the photometer invented by Messrs. Izard and Chibret. On 
looking through this instrument toward the sky two equally 
bright discs are seen. By a simple mechanism one of the 
discs can be made darker. If the eye does not perceive the 
difference in illumination between the two discs within five 
degrees its light-sense is abnormal, or we may say its L. D. 
(light difference) is too high. Again, if one disc be made 
quite dark, and be then gradually lighted, the patient is 
required to indicate the smallest degree of light, or L. M. (light 
minimum), by which he can observe the disc issuing from the 
darkness. This should not be more than one or two degrees. 

Another good method is that of Bjerrum, in which the light- 
sense is tested by gray letters on a white ground, the letters 
being constructed on the same principle as Snellen's test-types 
(see form-sense). 

Dr. Wallace Henry's (of Leicester) photometer * is probably 
the best for clinical use for estimating the L. M. In it there 
is no confusion of the light-sense with the form-sense, and the 
light used is a constant one. The instrument consists of an 
oblong box (A, Fig. 8), open at the anterior end, through 
which the patient looks ; to the margin of this opening a hood 
(F) is affixed, which is drawn over the patient's head during 
the examination, in order to exclude any external light from 



* Ophih. Rev., February, 1896. To be had of Messrs. Salt& Son, of Birminj 
ham. 



THE SENSE OF SIGHT. 



27 



the candle. At the posterior end is an aperture, opposite 
which are nine discs of 15-ounce standard opal glass (B), 
so arranged that one by one they can be swung back. Behind 
that, on a bar (C), distant ^ of a meter from the box, is a 
standard candle (D) in a spring holder, keeping the flame at a 
constant level ; behind this is a shade (E) to prevent flicker- 
ing. The photometer rests on a stand (G). The patient is 
kept in the dark for five minutes, so that his retina may become 
adapted to the dark. He then sits as above described, the 
eye not under examination being closed with a shade which 
should cause no pressure. The opal discs are now removed 
one by one, and the patient is told to say when he first detects 




Fig. 8. 



any light. Should he detect it through seven opals, his L. M. 
is noted as seven ; if through six, five, four, etc., six, five, four, 
is entered. 

Dr. Henry finds that the L. M. is greatest in early and 
middle life, and that it then gradually diminishes with the ad- 
vance of years. Diseases primarily involving the nervous 
elements in the optic nerve show a tendency to defective L. D., 
while diseases primarily involving the choroid and retina cause 
defective L. M. The examination of the L. M. is valuable 
where the diagnosis, sometimes a difficult one, between atrophy 
of the optic nerve and chronic simple glaucoma is concerned, 



28 DISEASES OF THE EYE. 

as the L. M. is much reduced in the latter disease, and but 
sHghtly in the former.* 

The color-sense is the power the eye has of distinguishing 
light of different wave-lengths. According to the Young- 
Helmholtz theory, the retina possesses three sets of color- 
perceiving elements, those for red, green, and blue or violet. 
These are termed primary colors, all other colors being com- 
pounds of them. 

Accordincr to Herincr's theory, the color-sense and the lip-ht- 
sense depend upon chemic changes in the retina, or in the 
"visual substances" situated in the retina. He suggests the 
existence of three different visual substances, the white-black, 
the red-green, and the blue-}^ellow, by the using up or dis- 
similation, and restoration or assimilation, of which substances 
the sensations of light and color are produced. In the case 
of the white-black substance, the sensation of white, or of 
light, corresponds to the process of dissimilation ; while the 
sensation of black, or of darkness, corresponds to the process 
of assimilation. For the red-green and blue-yellow substances 
it cannot be said which color-sensation implies assimilation 
and which dissimilation. The members of the black-white 
pair can mingle with each other and with those of the other 
two pairs ; but the respective members of the two-color pairs 
(being "contrast colors") — ^. ^., blue and yellow, cannot 
unite with each other. 

In testing the color-sense the spectral colors are the best 
for exact experiments, but the difficulty of producing them at 



*The light-sense and the adaptation of the retina, altliough related functions, 
must not be confounded one with the other. By the latter is meant the power 
the retina has of gradually adapting itself to see when the individual passes from 
a bright into a dim light. When it cannot do this with normal rapidity, or to a 
normal degree, the symptom called night-blindness results. It is quite possible 
for the light-sense to be normal, and yet for the retinal adaptation to be very 
defective, and wV^ versa. 



THE SENSE OF SIGHT. 29 

every moment, and of combining them, renders them of little 
clinical use. 

The clinical method commonh' employed for testing the 
color-sense is that of Professor Holmgren, of Upsala, which 
is based upon the Young-Helmholtz theory. The test-objects 
used are colored wools, of which a large number of skeins of 
every hue are thrown together. 

Test I (inde card on inside of end cover) consists in pre- 
senting to the individual, in good diffused daylight, a pale but 
pure green sample, and requiring him to select out of the 
bundle of wools of all colors before him all of those samples 
which seem to him to correspond to the test sample. If he do 
this correcth', it is unnecessary to proceed further : the indi- 
vidual has normal color-sense. Amongst the skeins, however, 
there are some which are termed colors of confusion (grays, 
buffs, straw-colors, etc.) ; and if he select one, or several, of 
these he is color-bhnd. 

If, now, we want to ascertain the kind and degree of his de- 
fect, we proceed to Test II, a. A pink (mixture of blue and 
red) skein is given to be matched. If this be correctly done, 
we term the person incomplete!}' color-blind ; but if blue and 
violet, or one of them, be selected, he is red-blind (sees only 
the blue in the mixture of blue and red) ; if he select green 
and gray, or one of them, he is green-blind. 

In order to corroborate the investigation, we may employ 
Test II, b. X vivid red skein is given. The red-blind chooses, 
besides red, green and brown shades darker than the red ; 
while the green-blind chooses green and brown shades lighter 
than the red. But I beheve, myself, and I think it is now 
very generally recognized, that red-blindness and green-blind- 
ness invariably go together. In violet- or blue-blindness, 
purple, red, and orange will be confused in Test II, a^ but 
this is an extremely rare variety of color-blindness. Total 
color-blindness will be recognized by a confusion of all shades 



30 DISEASES OF THE EYE. 

having the same intensity of light, and is also rare. It is im- 
possible by this test for any color-blind person to escape de- 
tection, except in the case of a small central color scotoma.* 

The individual tested should not be allowed to name the 
colors, but merely to match them, as above described. The 
reason for this is twofold. First, because, although the con- 
genitally color-blind person is usually unaware of his defect, yet 
experience has taught him which of his sensations are called 
blue, red, etc., by other people ; and hence he can often apply 
the right names to colors which he really does not see as 
such. He is assisted in this by whatever of color-sight is left 
to him, and by the brightness and saturation of the different 
colors, but is liable to frequent mistakes. Again, when the 
color-blind person does happen to know of his defect, he is 
often desirous of concealing it, either because he is ashamed 
of it or from interested motives. f 

A certain proportion of people (3.5 per cent, of men and 
less than one per cent, of women) are congenitally color-blind 
in greater or less degree, without any diminution in the other 
visual functions. 

Acquired color-blindness is found in toxic amblyopia, in 
atrophy of the optic nerve, and under some other conditions. 

The form-sense (acuteness of vision) is the faculty the 
eye possesses of perceiving the shape or form of objects, and 
in clinical ophthalmology the testing of this function is an im- 
portant and ever-recurring duty. 

In order that an eye may have good sight it is necessary, 
not only that its optic nerve, retina, choroid, and refracting 
media be healthy, but also that its refraction and accommoda- 
tion be normal. When applied to by a patient on account of 



* See case reported by MacGillivray, Brit. Med. Jour., July, 1892. 
t More detailed information on color-blindness and Holmgren's test will be 
found in Appendix I. 



THE SENSE OF SIGHT. 31 

imperfect sight it is our first dut}^, as a rule, to ascertain ac- 
curately the condition of refraction and accommodation of his 
eyes. Should these be abnormal, and it be found that by aid 
of the correcting glasses perfect vision is obtained, we may in 
general conclude that the eye is organically sound, and that 
the patient's complaints are due to the defect in accommoda- 
tion or refraction, If the glasses do not restore perfect vision, 
we must then, by the ophthalmoscope and other methods, de- 
cide the nature of the defect. 

By acuteness of vision (V.) is meant the power which an 
eye, or rather its macula lutea, has of distinguishing form, any 
anomaly of its refraction, if such exist, having been first cor- 
rected — i. c, while the patient wears the correcting glasses. 

Now, in order to measure the acuteness of vision we must 
have a normal standard for comparison — /. e., we must find 
what is the size of the smallest retinal image whose form 
can be distinguished. We cannot measure this image directly ; 
but, as its size is proportional to the visual angle — the angle 
which the object subtends at the eye — it is sufficient to deter- 
mine the smallest visual angle under which the form of an 
object can be distinguished. It has been found, experiment- 
ally, that the average size of this angle is five minutes. 

In order practically to ascertain the degree of acuteness of 
vision, we place our patient with his back to the light, while 
facing him at a distance of six meters, and in good Hght, are 
placed Snellen's test-t\'pes for distance. These types are 
so designed that at the distance at which they should be seen 
they each subtend an angle of five minutes at the eye. The 
largest type should be seen at 60 meters (Fig. 9) by the nor- 
mal eye, and the types range from this down to a size visible 
not further off than six meters. If V = acuteness of vision, 
d = the distance from the eye to be tested to the test-types, 
and D = the distance at which the type should be distinguish- 
able, then V = — . For example : if d ^ six meters, a dis- 



32 DISEASES OF THE EYE. 

tance which most rooms can command, and if the eye sees 
type D = 6, then V = |- ^ i, or normal V. ; but if at six 
meters the eye sees only D = 60, which should be seen at 
60 meters, then V = -^, or very imperfect vision. 

Should the patient's sight be so bad that he is unable to 
read any of the letters, it may be tested by trying at what dis- 
tance he can count the surgeon's fingers ; and if he cannot 
even do that, then his power of perception of light, his P. L., 
should be tested. This is done by means of a lamp in a 
dark room, the eye being alternately covered and uncovered, 
and the patient being required to say when it is "light " and 




Fig. 



when "dark." If the flame be gradually lowered, the small- 
est degree of illumination perceptible will be ascertained. 

The eyes must be examined separately, that one not under 
examination being excluded from vision by being shaded with 
the patient's own hand or other suitable screen ; but it must 
not be at all pressed on, as any pressure would dim its vision 
when its turn for examination may come. 

With the advance of age the acuteness of vision undergoes 
a slight but steady reduction, owing to certain senile changes 
in the eye.* 

* Von Gi-aefe' s Airhiv, xxxix, ii, p. 71. 



THE FIELD OF VISION. 33 

THE FIELD OF VISION. 

By the field of vision (F. V.) is meant the space within 
which, when one eye is closed, objects can be seen by its fel- 
low, the gaze of the latter being fixed the while on some one 
object or point. Thus, if standing on a hill, we fix the gaze 
of one eye on some object on the plain below, the field of 
vision includes not only that object, but many others also for 
miles around it. If the fixation object be nearer to us, the 
area taken in by our field of vision will be proportionately 
diminished in extent. 

The fixation object is seen by central or direct vision, its 
image being formed on the macula lutea ; the other objects 
in the field of vision correspond with as many different points 
in the more peripheral parts of the retina, and are seen by 
eccentric, or indirect, vision. Eccentric vision is of great im- 
portance for the guiding of ourselves and avoiding obstacles 
in our w^ay. Its use may be realized by the experiment of 
looking through a long, small-bore cylinder (^. g., a roll of 
music) with one eye, thus cutting off its eccentric field while 
the other eye is closed. 

The dimensions of the field of vision may be measured 
for clinical purposes by means of an instrument called the 
perimeter. This is a semicircular metal band which revolves 
upon its middle point, being in this way capable of describing 
a hemisphere in space. The arc is divided into degrees 
marked on it, from 0° placed at its middle point to 90° at 
either extremity. At the center of the hemisphere is situated 
the eye under examination, while the fixation point is placed 
exactly opposite, in the center of the semicircle. A small bit 
of white paper, five mm. square, the test object, is slowly moved 
along the inner surface of the arc from the periphery tow^ard 
the center until it comes into view, and this point is observed 
in various meridians. The horizontal, vertical, and two inter- 
3 



34 



DISEASES OF THE EYE. 



mediate meridians, at the least, should be examined by plac- 
ing the arc of the perimeter in the corresponding planes. 
The boundary of the field may be noted on a diagram or 
chart (Fig. lo), which represents the projection of a sphere 
on a plane surface. 

The radii represent different meridians, which may be deter- 




FiG. lo. — Chart of F. V. of Right Eye. 



mined by a dial with pointer on the back of the perimeter, 
while the concentric circles correspond with the degrees 
marked on the arc. A pencil mark is placed on the chart at 
the spot corresponding to that on the perimeter at which the 
test object comes into view, and when the different meridians 



THE FIELD OF VISION. 



35 



have been examined these marks are united by a continuous 
Hne, which then represents the outer boundaiy of the F. V. 

The normal F.V. is not circular, but extends outward about 
95°, upward about 53°, inward about 47°, and' downward 
about 65°, as represented by the strong curve in figure 10. 
The limitation upward and inward is partly due to the pro- 
jection of the supra-orbital margin and the bridge of the nose, 
but also to the fact that the outer and lower parts of the 




Fig. II. 



retina are less practiced in seeing than are the upper and inner 
parts, and their functions consequently less developed. The 
acuteness of vision diminishes progressively toward the per- 
iphery of the field, two points of a certain size close together 
being distinguishable from each other only a short distance 
from the fixation point, while the further toward the periphery 
the larger must be the test objects. 

Figure 1 1 serves to illustrate the projection of the field of 



36 



DISEASES OF THE EYE. 



vision on the semicircle of the perimeter to its extreme tem- 
poral (95°) and its extreme nasal (47°) boundaries, as well as 
the portion of the retina (a to U) which corresponds to this 
extent of field, and it shows that the sensitive portion of the 
retina, or rather, perhaps, the portion of the retina which is 
most used, extends further forward on the nasal than on the 




temporal side. The diagram also explains the remarkable 
fact that the field extends in the temporal direction more than 
90°. It must be remembered that the fields of vision overlap, 
as the two visual axes meet at the fixation point. Figure 1 3 
represents the binocular portion, white, P being the fixation 
point. The shaded portion on the right belongs to the right 



THE FIELD OF VISION. 37 

eye alone, while that on the left belongs to the left eye 
alone. 

The Blind Spot of ]\Iariotte is a small bHnd island or sco- 
toma in the F. \'., situated about 15° to the outer side of the 
point of fixation and just below the horizontal meridian. It 
is shown as a white spot in figure 12. It is due to the optic 
papilla, for at that place the outer layers of the retina are 
wanting, and hence there is there no power of perception. 
There are also, occasionalh', minute blind spots in the field, 
due to large retinal vessels, which interfere with the formation 
of the image upon the layer of rods and cones. 



qo» 




Fig. 13. — Binocular Field of Vision. 

Tlie perception of colors in the pcripliery of the field can be 
examined with the perimeter by means of bits of colored paper 
five mm. square. It has been in this way ascertained that 
the boundaries of the power of eccentric perception for the 
different colors do not seem to correspond with the boundan' 
for white light, nor do the boundaries of the different colors 
seem to coincide. Examining from the periphery toward the 
center b}- ordinary da}'light. blue is the color which can be 
distinguished as such most eccentricalh*, its field extendingr 
nearly as far as the general F.\^. ; then come yellow, orange, 
red, and, with the most limited field, green. Blue, red, and 



38 DISEASES OF THE EYE. 

green being the most important, their fields are noted in figure 
1 1. Although the respective colors are distinguishable within 
the limits indicated, they are by no means so brilliant in hue 
as when seen by direct vision. It has, however, been demon- 
strated that every color is recognizable up to the outer limit of 
the F. v., if the colored object be of sufficient surface and be 
sufficiently illuminated ; so that there is, in fact, no absolute 
color-blindness in the peripheral parts of the retina, but merely 
a diminished sensitiveness to colored light. 

The perception of form in the periphery of the field is very 
defective, and its examination is not of much practical import- 
ance ; but this portion of the field is very sensitive to the 
movements of objects. 



CHAPTER 11. 

ABNORMAL REFRACTION AND 
ACCOMMODATION. 

I have explained what is meant by normal refraction, or 
emmetropia. We recognize three different forms of abnormal 
refraction, or ametropia (a^ priv. ; ixirpov, standard; &if). i. 
Hypermetropia {ovitp, over ; jjArpov, standard ; a)(f), in which 
the principal focus of parallel rays of light lies behind the 
retina. 2. Myopia (//.6£fv, to close ; w0), or short-sight, in 
which the principal focus of such rays lies in front of the retina. 
3. Astigmatism (a, priv. ; (rxiYixa, a point), in which the re- 
fraction of the eye in its different meridians is different. 

Hypermetropia. 

In a large proportion of cases this form of ametropia is due 
to the eyeball being too short in its antero-posterior axis 
(Axial H.). It may also depend upon deficient refracting 
power in the dioptric media (Curvature H.). 

Parallel rays of light falling into the hypermetropic eye 
{E, Fig. 14) do not meet on the retina, but converge toward 
a point (c) situated behind it. Consequently these rays do 
not form on the retina a distinct image of the object looked at, 
but produce there a circle of diffusion {d e), or blurred repre- 
sentation of the object. 

Since, therefore, in hypermetropia the retina is in front of 
the principal focus of the dioptric system, rays passing out of 
the eye from any point (^R, Fig. 15) on this retina will pass 
out as divergent rays, and will appear to come from a point 

39 



40 



DISEASES OF THE EYE. 



(R^) situated behind the eye, which point is the virtual con- 
jugate focus of the point R. 

Now, in order to correct the hypermetropia — so that parallel 
rays passing into it may be brought to a focus on the retina — 
a convex lens (L, Fig. i6) must be placed in front of the eye, 




Fig. 14. 

of sufficient strength to render the parallel rays, before they 
enter the eye, convergent toward R^ , so that when they meet 
the eye they may be brought to a focus on the retina R, which 
is the conjugate focus o{ R' . The higher the hypermetropia 
— /. e., the shorter the antero-posterior axis of the eyeball, the 
stronger must the correcting glass be. It may be found that. 




Fig. 15. 

with a lens of some dioptrics less power, the eye will see 
equally well ; but this it does by means of an effort of accom- 
modation which supplements the inadequate refracting power 
of the lens placed before it. As we proceed to higher lenses 
the effort of accommodation is relaxed, until, finally, the 



HYPERMETROPIA. . 41 

strongest lens with which vision is still at its best is reached, 
when, it may for the present be assumed, no further effort of 
accommodation is made, and L represents the whole error of 
refraction. In low degrees of hypermetropia the e}'e can 
frequently see distant objects distinctly by an effort of accom- 
modation, which completely takes the place of L. When 
such an eye is found to have full vision without a glass a 
beginner might fall into the error of regarding it as emmetropic ; 
but if he take the precaution of placing a low convex lens in 
front of it, and then find that the acuteness of vision — the 
effort of accommodation now being relaxed — remains as good 
as without the glass, he will avoid this mistake. 

If a glass a single number higher than the exact measure 




Fig. 16. 

of the defect be placed before the e}^e, vision again becomes 
indistinct, because the rays are then brought to a focus in 
front of the retina, and a circle of diffusion is formed on the 
latter. The eye, in fact, is put by such a glass in a condition 
of myopia. Therefore tJie strongest convex glass zuith whicli a 
Jiypernietropic eye can see distant objects {the test- types) most dis- 
tinctly is the glass which corrects its hypermetropia, and is the 
measure of the latter. Very commonly it is only the manifest 
hypermetropia (vide infra) which is ascertained by this method, 
unless the accommodation has been previously paralyzed by 
atropin. 

This method of determining the refraction by means of the 
4 



42 DISEASES OF THE EYE. 

trial-lenses and test-types is not relied on nowadays by 
ophthalmic surgeons to the same extent as formerly, the 
examination of the upright ophthalmoscopic image, or else 
retinoscopy, having largely taken its place. In conjunction 
with these it is a valuable method. 

The degree of the hypermetropia is indicated, as has been 
said, by the number of the lens which corrects it.* Thus, if 
the number of the glass (A, Fig. i6) required to correct the 
hypermetropia of the eye {E) be 2.0 D, we say this eye is 
hypermetropic two dioptries, or has a hypermetropia of two 
dioptrics, or we would write it down (H = 2.0 D). 

Amplitude of Accommodation in Hypermetropia. — When at rest, the 
refraction of the hypermetropic eye is deficient : consequently r must be negative 
( — r), and the amplitude of accommodation must include the power required to 
adapt the eye to infinity ; therefore 

For example : if the punctum proximum of a hypermetropic eye of five D be 
at 30 cm. , what is the amplitude of accommodation ? Five D ( ^ r) is necessary 
in order to make the eye emmetropic, and to accommodate the emmetropic eye 
to 30 cm., 3.25 D (LOqP == 3.25) is required. Hence «: = 3.25 -f- 5 = 8.25 D. 

The Angle 7 in Hyper- 
metropia. — In hypermetropia, 
as in emmetropia, the cornea is 
cut to the inside of its axis by 
the visual line ; but in hyper- 
metropia the angle which the 
visual line forms with the axis 
of the cornea is very much 
greater, owing to the shortness 
Fig. 17. of the eyeball, the effect of 

which is to increase the distance 
between the macula lutea [M) and the optic axis [A] (Fig. 17). Consequently, 
in extreme cases, when the visual lines of a hypemaetropic individual are directed 
to an object, the axes of the cornese may seem to diverge, and thus the appearance 
of a divergent strabismus will be given (apparent strabismus, see Chap, xviii). 




* Theoretically, the glass which measures the error of refraction should be in 
contact with the eye, but for practical purposes the distance between the glass and 
the eye may be neglected, especially if the glasses are worn at the same distance 
from the eye as they occupied during the testing. 



HYPERMETROPIA. 43 

The eyes of animals and of uncivilized nations are hyper- 
metropic ; children, too, are hypermetropic at birth, but as 
they grow older the refraction increases and they become less 
hypermetropic, or emmetropic, or even myopic. 

The evil effects of the constant and excessive demand upon 
the accommodation in hypermetropia are chiefly these : 

I. Cramp of the Ciliary Muscle. — Its persistently main- 
tained contraction frequently gives rise to a tonic cramp of the 
muscle. This spasm is not, or may be only partially, relaxed 
when the correcting convex glass is held before the eye, and 
consequently the whole or part of the hypermetropia may be 
masked by the cramp. That part of the hypermetropia which 
is thus masked is called latent (HI.), while the part which is 
revealed by the convex glass is called manifest (Hm.). The 
entire hypermetropia is made up of the latent and manifest H. 
(H. = Hm. -K HI). 

If the cramp be excessive, parallel rays may be kept con- 
vergent on the retina by it alone, and vision then would be 
made worse, rather than better, by even a weak convex glass 
held before the eye, a circumstance which might lead the 
surgeon to think he had to do with an emmetropic eye. In 
this case we say that the whole hypermetropia is latent. 

Or, in extreme cases of accommodative spasm, parallel rays 
may be united in front of the retina, and the eye made ap- 
parently myopic, the vision being capable of improvement by 
concave glasses. Serious errors might therefore arise if this 
cramp were overlooked, as it is very apt to be in the examina- 
tion with the trial-lenses. When it is present in a high degree 
the patient cannot maintain a sustained view of an object at 
any distance without suffering pain in and about the eyes. It 
is frequently the reason why perfect acuteness of vision is 
not obtained by aid of the trial-lenses, and the surgeon must 
be careful not to be led into an error of diagnosis by it. 
Examination with the ophthalmoscope, or paralysis of accom- 
modation with atropin, will enable him to avoid mistakes. 



44 DISEASES OF THE EYE. 

In order to relieve this cramp, the ciliary muscle must be 
paralyzed by a solution of atropin freely instilled ; and it 
will often be necessary to keep the accommodation paralyzed 
for some days, and to commence the use of the correcting 
spectacles before the effect of the atropin begins to wear off. 
In this way a recurrence of the spasm may be often prevented. 

As life advances and the power of accommodation dimin- 
ishes, the manifest part of the hypermetropia increases, while 
the latent part decreases, until finally Hm. = H. 

2. Accommodative Asthenopia. — In looking at distant 
objects, the accommodation of the normal eye is at perfect 
rest, and does not come into play until the object is ap- 
proached close (within six meters) to the eye. But even for 
distant objects the hypermetropic eye must accommodate ; 
and, having for those distances used up part of its accommo- 
dative energy, it has for near objects actually less at disposi- 
tion than the normal eye. Hence we find that hypermetropic 
people often complain of inability to sustain accommodative 
efforts for near objects for any length of time. After reading, 
sewing, etc., for a short time, sensations of pressure in the 
eyes and of weight above and around them come on, and the 
words or stitches become indistinct, and cannot be distin- 
guished. The work must then be interrupted, and after a few 
minutes' rest it can be resumed, but must soon again be given 
up. After a Sunday's rest the patient is often able to get on 
better than on the previous Saturday. These symptoms de- 
pend simply upon inability of the ciliaiy muscle to perform 
the excessive demands made upon it. 

Accommodative asthenopia {a, priv. ; aOhoq, strength ; w^), 
as this group of symptoms. is called, often appears suddenly 
during or after illness. The explanation of this is that, al- 
though hypermetropia had always existed, yet in health the 
ciliary muscle was equal to the great efforts required of it, 
but in sickness it shared the debility of the system in general. 
To relieve accommodative asthenopia, we have merely to pre- 



MYOPIA. 45 

scribe those lenses for near work which correct the hyperme- 
tropia, and by this means to place the eyes in the position of 
emmetropic eyes. 

3. Internal, or Convergent, Concomitant Strabismus. 
— This condition has a certain relation to hypermetropia. It 
will be treated of in the chapter on the Motions of the Eye- 
balls and their Derangements (Chap. xxi). 

The Prescribing of Spectacles in Hypermetropia. — If 
a person be found to be hypermetropic, but his acuteness of 
vision without glasses be good, or as good as he desires, and 
he complain of no asthenopic symptoms, glasses need not, 
indeed should not, be prescribed for him. No disease in his 
eye will result from his going without glasses. 

If the patient complain of imperfect distant vision, due to 
hypermetropia, then those lenses which correct the Hm. may 
be prescribed for distant vision, to be worn either constantly 
or occasionally, as he may desire. Such a patient is almost 
certain to complain also of accommodative asthenopia ; while 
many patients will be met with who complain of the latter, 
yet express themselves as perfectly satisfied with their distant 
vision. For relief of the asthenopia it is usually enough to 
prescribe spectacles for near work which will correct the Hm., 
along with one D or two D of the HI., if the latter exist. 

If there be excessive cramp of accommodation, glasses to 
correct the whole hypermetropia should be worn while the 
eye is under atropin ; and afterward as much of the HI, as 
possible, along with the Hm., should be corrected by glasses 
to be worn constantly. 

Myopia, or Short-sight. 
This form of ametropia is due, in a vast majority of cases, 
to the antero-posterior axis of the eyeball being too long 
(Axial M.), and hence, its refracting media not being pro- 
portionately diminished in power, parallel rays of light 



46 



DISEASES OF THE EYE. 



{a b, Fig. 1 8) are not brought to a focus on the retina, but in front 
of it (at /"), and form on the retina circles of diffusion (c d). 

Myopia may also be caused by abnormally high refracting 
power in the crystalline lens, as in spasm of the ciliary muscle, 




and in some cases of commencing cataract, and also by coni- 
cal cornea (Curvature M.). 

Since, in the myopic eye, the retina is beyond the principal 
focus of the dioptric system, rays emerging from any point 
(r. Fig. 19) of the fundus will pass out convergently, and will 




Fk;. 19. 
unite in front of the eye at the conjugate focus of the retina 

Conversely, rays diverging from a certain point (/') in front 
of the eye will be focussed on the retina (r). 

If an object be brought toward the eye, the divergence of 
those rays which pass from it into the eye increases, until, 



MYOPIA. 47 

when it has reached the point r, their divergence is just suffi- 
cient to allow them to be united at the conjugate focus c, 
which is on the retina. This point r is the punctum remotum * 
of the myopic eye. In order, therefore, that the short-sighted 
eye may be able to see distant objects, it is necessary that the 
parallel rays coming from those objects should be given such 
a degree of divergence before they pass into the eye as though 
they came from this punctum remotum. This can readily be 
effected by placing the suitable concave lens in front of the 
eye, and the number of this glass will indicate the degree of 
the myopia — /. r., by how many dioptrics the refracting power 
of the eye is in excess of that of an emmetropic eye. The 




Fig. 20. 

focal length of the correcting glass corresponds, of course, 
with the distance of the punctum remotum from the eye, pro- 
vided the glass be held close to the cornea. The focus of the 
glass and the punctum remotum of the eye are then identical, 
and therefore parallel rays, after passing through the glass, will 



■^ The punctum remotum is always the conjugate focus of the retina. In an 
emmetropic eye it is at infinity, since the retina is at the principal focus of the 
eye, and the rays pass out parallel. In hypermetropia it is behind the eye, and 
is virtual or negative, because the retina is in front of the principal focus, and 
the rays pass out divergently, as if coming from a point behind the retina. Lastly, 
in myopia, it is situated at a finite distance in front of the eye, and is real and 
positive, because the retina is beyond the principal focus, and the rays emerge 
convergently. 



48 DISEASES OF THE EYE. 

have a divergence as though they came from this point, and 
will form an exact image of the object from which they come 
on the retina. 

For example : if the punctum remotum (Fig. 20) be situ- 
ated at 14 cm. from the eye, then the number of the correcting 
lens will be seven D, because the focal distance of this lens is 
14 cm. {-jj- = 7). In practice, however, we cannot hold the 
glass so close to the cornea, and therefore we must subtract 
the distance between it and the cornea from the focal distance 
of the required lens. In the above case, suppose the distance 
from cornea to glass be four cm., the required lens will be ten D 

(-VV-='o). 

Determination of the Degree of Myopia. — ^The degree 
or amount of myopia, as of hypermetropia, may be deter- 
mined either by the ophthalmoscope, or experimentally by 
means of the trial-lenses and test-types. 

By the latter method, examining each eye separately, we 
find the correcting glass by placing our patient as directed in 
the section on Acuteness of Vision. A weak concave trial- 
glass is then held before the eye under examination, and 
higher numbers are gradually proceeded to until the glass is 
reached which gives the eye the best distinguishing power for 
the types. We often find that there are several glasses, with 
each of which the patient can see equally well. The iveakcst 
of these is the measure of his myopia. When a higher glass is 
used the eye may still see well, but it does so only by an effort 
of accommodation, and the glass employed represents not 
merely the myopia present, but also this accommodative effort. 
No more serious mistake can be made than the prescribing of 
too strong concave glasses for a myopic individual, as will be 
seen further on. 

The Amplitude of Accommodation in Myopia. — The myopic eye has an 
excess of refractive power as compared with the emmetropic eye ; therefore, in 
calculating its amplitude of accommodation, this excess must be subtracted from 



MYOPIA. 49 

the positive refractive power (/) which would be required to adapt the emmetropic 
eye to the same punctum proximum ; or, in other words, the myopic eye has need 
of less accommodative power than the emmetropic eye, because, even at rest, it is 
adapted for a distance (R., its punctum remotum) for which the emmetropic eye 
has to accommodate ; hence in myopia, 

« = / — r. 

For example : a myopic person of ten D, who can accommodate up to eight cm. 
{p =^ 1|- ^= 12 D), has an amplitude of accommodation of 12 — 10 = 2 D. 

The Angle 7 in Myopia. — In myopia, owing to the length of the eyeball, 
the cornea is cut much closer to its center by the visual line than in emmetropia, or 
these two lines may coincide, or the cornea may even be cut to the outside of its 
center by the visual line [vide Fig. 21). In any of these cases, but especially in 
the latter, the effect will be that of an apparent convergent strabismus. 

Myopia is rarely or never congenital, but is, for the most 
part, the result of the demands made upon the eyes by 




Fig. 2 



modern civilization. It generally first shows itself from the 
eighth to the tenth year, and is apt to increase, especially 
during the early years of puberty. Its progressive increase 
is encouraged by use of the eye for near work, such as read- 
ing, sewing, drawing, etc., and is due to a further elongation 
of the antero-posterior optic axis. But it is certain that in 
addition to this exciting cause there must be some predis- 
posing condition or conditions, as only a few children become 
short-sighted, although they are all educated in a very 
similar manner, so far as the use of their eyes is concerned. 
Moreover, high degrees of myopia are occasionally met with 
in young children before they have begun to use the eyes 



50 DISEASES OF THE EYE. 

much for close work. Stilling * and Seggel f have found that 
a low orbit is usually associated with a myopic formation of 
eyeball, and they are inclined to regard these largely in the 
light of cause and effect. For with a low orbit, and when, 
as often happens, the tendon of the superior oblique has an 
almost transverse direction, the combined pressure of the two 
obliques upon the plane of the equator during the period of 
growth would tend to cause elongation of the antero-posterior 
diameter of the eyeball. Opposed to this view is the fact that 
in scholars of Esthic nationality, who have broad faces and low 
orbits, the proportion of myopes is less than in Europeans. J 
Certain it is that myopia is often hereditary, and seen in 
several members of a family. The whole question of the pre- 
disposing causes of myopia must still be regarded as sub 
pidice. 

In cases of commencing cataract a slight degree of myopia 
may sometimes be noticed to come on. This is due to a 
higher refracting power in the lens, as the result of the 
changes beginning in it. 

Hirschberg § states that late myopia, coming on without 
cataract from the fortieth to the sixtieth year, is a very certain 
sign of diabetes. He offers no explanation of its occurrence 
in this way. I have not myself seen such a case. 

Many short-sighted people half close their eyes when 
endeavoring to distinguish distant objects, in order that the 
rays may be prevented, so far as possible, from passing 
through peripheral parts of the crystalline lens, which would 
increase the circles of diffusion. This habit it is which has 
given the name of myopia to the condition. 

* Trans. Internat. Ophth. Congress, l888, p. 97. 
f Von Graefe'' s Archiv, xxxvi, ii, p. I. 
% Pymsza, Inaug. Dissert. Dorpat, 1892. 
\ Deutsche Med. Woc/iensc/ir., 1 89 1, No. 1 3. 



MYOPIA. 51 

Progressive myopia frequently becomes complicated 
with organic disease, viz.: i. Posterior Stapliyloina. — This 
condition is recognized by the ophthalmoscope as a white 
crescent at the outer side of the optic papilla. Owing to 
bulging of the eyeball the choroid becomes atrophied at this 
place, and admits of the white sclerotic being seen. The 
staphyloma sometimes extends all around the optic papilla, and 
by stretching of the retina in these extreme cases its functions 
may become deranged, and in consequence the blind spot in- 
creased in size. 

2. CJioroidal Degeneration in tlie Neigliborhood of the Mactila 
Lutea. — This should always be carefully looked for, as the re- 
gion of the yellow spot is very liable to disease in bad cases 
of progressive myopia. The disease seems to begin in the 
choroid, giving the appearance of small cracks or fissures, 
which later on develop into a patch of choroidal atrophy. The 
retina at the spot becomes disorganized, and very serious dis- 
turbance of vision is the result, the patient being disabled from 
reading. 

3. Heniorrliage in the retina at tJie yellow spot may occur, 
causing similar visual defects ; and when the hemorrhage be- 
comes absorbed the macula lutea may not recover its function, 
owing to the delicate retinal tissue having been seriously 
damaged. Yet we often meet with cases of this kind which 
do regain their former vision. 

4. Detaclinient of the Retina. — This is a frequent and most 
serious complication of progressive myopia. It will be fully 
considered in the chapter on Diseases of the Retina (Chap. xv). 

5. Opacities in the Vitreous Humor. — These often accompany 
the choroidal alterations. 

Insujfciency of the internal recti muscles is another anomaly 
which we find very commonly associated with progressive 
myopia ; but it can hardly be regarded as an organic disease, 
or as a result of progressive myopia. It may more properly 



52 DISEASES OF THE EYE. 

be looked upon as a concomitant congenital irregularity, and 
perhaps as one of the causes of the progressiv^e nature of 
myopia. It will be fully discussed in chapter xviii. 

Cramp of accoimnodation is often present in myopic eyes, 
and will cause the myopia, examined with trial-lenses and test- 
types, to seem higher than it is. The surgeon, being aware 
of this source of error, will guard against it. 

In some cases of myopia a peculiar bright crescentic reflex, 
first described by Weiss, can be seen close to the nasal side 
of the disc. Its significance has not yet been positively 
ascertained. 

The Management of Myopia. — The great danger of 
myopia being its progressive increase, with consequent or 
attendant organic disease, its management is one of our most 
important and difficult tasks, especially in these days of high- 
pressure education. Many cases of myopia are not progress- 
ive, and cause no anxiety ; others are periodically progressive ; 
and, again, others are continuously or absolutely progressive. 
In the periodically progressive form the age of puberty is 
usually the time of greatest increase and greatest danger, the 
myopia often becoming stationary later on. In the absolutely 
progressive cases the increase goes on rapidly until after 
puberty, and then more slowly ; but it usually leads to con- 
siderable loss of vision, unless the greatest care be taken. 

In the progressive forms, close approximation of the eyes 
to the work, meaning convergence of the visual lines and 
accommodative effort, as, also, everything which tends to cause 
congestion of the eyes and head, are what we have to try to 
prevent. In order that these patients may not be obliged to 
approach close to their work, they should occupy themselves 
with large and not with minute objects, and only by good light. 
When possible (indc infra) such spectacles should be prescribed 
for them as will enable them to read at a distance of 25 to 
30 cm. In reading and writing the books and papers should 



MYOPIA. 53 

be on a slope, to facilitate an upright position of the head, and 
the table should not be too low. They should pause to rest 
for some minutes occasionally during the spell of work, while 
the number of working hours in the day should be restricted. 
The action of the bowels should be regulated, the feet kept 
warm, and all excessive bodily exertion avoided, so that con- 
gestion of the head and eyes may be prevented. Where 
posterior staphyloma, hemorrhages at the macula lutea, or 
opacities in the vitreous humor are present, Heurteloup's arti- 
ficial leech applied to the temple, mild purgatives, and com- 
plete rest of the eyes, with the use of atropin for some weeks 
to immobilize the ciliaiy muscle, are to be ordered. If the 
choroid changes be very marked, small doses of the per- 
chlorid of mercury are indicated. The eyes should be pro- 
tected from light by blue or smoked protection-spectacles, this 
latter precaution being especially necessary during the use of 
atropin. Insufficiency of the internal recti should be cor- 
rected by prisms or by operation. 

The correction of the myopia by suitable glasses is an im- 
portant and difficult matter. In some cases of slight myopia 
(2.5 D and less), in }-oung patients with good amplitude of 
accommodation, the correcting glasses may be prescribed to be 
worn constantly, for near as well as for distant objects, and 
thus the patient is placed in the position of an emmetrope. 
In other cases, where the error of refraction is not excessive 
and the eye is organically healthy, the whole defect may be 
corrected for distant vision, if the individual be warned not to 
use his glasses for near work lest he should strain his accom- 
modation. In high degrees of myopia strong glasses may be 
given for distant vision, but it is wise to give them one D 
or 1.5 D less than the full correction, so that all danger of 
accommodative effort may be avoided. In these same cases, 
provided there be no ophthalmoscopic changes, or only some 
of minor significance, and if the vision be good, such a glass 



54 DISEASES OF THE EYE. 

may be given as will enable the patient to read at 25 to 30 
cm. This glass may be found by subtracting from the num- 
ber of the glass representing the degree of the myopia (say 
seven D) the lens whose focal length corresponds to the dis- 
tance (say 30 cm.) required (this, here, would be 3.25 D, 
because -Ig^- = 3.25, and then 7.0 — 3-25 ==3.75 D, the glass 
required). By aid of such glasses this myope can read at 
a distance much more favorable for the convergence of his 
optic axes and for the erect position of his head ; but there is 
a danger associated with their use — namely, that if the patient 
approach his book closer than the prescribed distance, he does 
away with the advantage he should gain from them, and, by 
necessitating an effort of accommodation, turns them to a 
serious source of danger for the eye. Patients in whom the 
acuteness of vision is much lowered are liable to approach 
their work in this way, in order to obtain larger retinal images, 
the more so as the concave glasses diminish the size of the 
images, and in such cases it is better not to give glasses for 
near work. It is often necessary to provide patients with 
spectacles which will enable them to use their eyes for some 
special purpose at a given distance — c. g.^ the pianoforte, paint- 
ing, etc., and these can be found as above explained. 

Operative Cure of Myopia. — This consists in the removal 
of the crystalline lens, and was first systematically employed 
by Fukala.* Some surgeons simply extract the lens by one 
of the methods used for cataract, while the majority first per- 
form discission of the lens, and when it has swollen and be- 
come cataractous they proceed to evacuate it through a linear 
corneal incision. In preference to either of these methods, I 
recommend discission pure and simple, allowing the process 
of absorption to go on until the whole lens gradually disap- 
pears. I do not evacuate the opaque lens matter through a 

"^Von Graefe''s Archiv, xxxvi, pt. ii, p. 232. 



MYOPIA. 55 

corneal incision, unless compelled to do so by increased ten- 
sion or other complications. I believe the discission pure and 
simple is not only the safest method as an operative proceed- 
ing, but is also less likely to be followed by any intraocular 
complication, such as detachment of the retina, or hemorrhage, 
than where a sudden reduction in the contents of the eyeball 
is effected, as by either of the other methods. Moreover, 
the disfigurement caused by the corneal incision, slight though 
it be, is a drawback from which the simple discission is free. 
Nor, again, is astigmatism so apt to be present. The cure by 
simple discission has the disadvantage of being rather tedious. 

The operative cure of myopia is not to be recommended 
except for cases of ten D and more, nor should it be per- 
formed where there is serious disease of the fundus or vit- 
reous humor. An ordinary posterior staphyloma does not 
form a contraindication. The best time of life for the cure 
is in childhood or early youth, but it can be successfully un- 
dertaken at a much later period. In the myopic eye the nu- 
cleus of the lens undergoes sclerosis to a less extent than in 
hypermetropia or in emmetropia, and hence in it discission is 
less apt to be followed by high tension or other complication, 
even when performed in middle age. 

The advantages gained by the patient from the operative 
cure of his myopia are enormous, while the risks to be run 
are slight. Not merely does the patient become either only 
slightly myopic, or else emmetropic or hypermetropic, ac- 
cording to the degree of the original myopia, but his acute- 
ness of vision is usually increased in a remarkable degree. 
One of my patients, with My. 20 D and V. = finger count- 
ing at two m., obtained, after discission and resulting absorption 
of the lens, an emmetropic eye, and V. = y^g^. The cause of 
this improved acuteness of vision is not clearly understood, 
and in some cases it goes on for several months before it 
reaches its height. Another remarkable point, illustrated, 



56 DISEASES OF THE EYE. 

too, by the above case, is that the amount of reduction in the 
refraction of the eye is much greater in these cases than one 
would a pjHori QXTiQct. A convex lens of about ten D is 
commonly required to correct an emmetropic eye that has 
been operated on for cataract, which would imply that the re- 
fracting power of the crystalline lens is about -J- lo.o D in 
the emmetropic eye. But, after the operative cure of myopia, 
it is found that the reduction in the refraction of the eye 
amounts to from 12.0 D to 20.0 D, and varies in different eyes. 
It would seem, then, that the lens in the myopic eye has a 
much higher refracting index than in emmetropia or in hyper- 
metropia, and that it has not the same power in every myopic 
eye. Convex spectacles require to be worn for near work 
after the operation, and sometimes, too, for distant vision, 
where hypermetropia has been produced. When the original 
myopia is not more than 10 D to 13 D, it is, I find, advisable 
in patients who follow certain callings in which the wearing 
of glasses is objected to, to operate on only one eye, which 
then subsequently serves for distant vision, while the unop- 
erated eye is used for reading and other near work, and by 
this means the patient is entirely independent of glasses. 
But, of course, binocular vision is sacrificed. 

Astigmatism. 

This is a compound form of ametropia, due to the cornea 
being more curved in one meridian than in another, similarly 
as the back of the bowl of a spoon is more convex from side 
to side than from heel to point. 

In regular astigmatism the directions of the greatest and 
least curvations of the cornea are always at right angles to 
each other, and usually fall precisely in the vertical and hori- 
zontal meridians, the meridian of greatest curvature being 
most frequently the vertical. Consequently, we say the 
astigmatism is "with the rule" in those cases in which the 



ASTIGMATISM. 57 

meridian of greatest curvature is the vertical ; and, where that 
meridian is the one of least curvature, we say the astigmatism 
is ''against the rule." The result of this is that a pencil of 
rays passing into the eye, instead of meeting at a common 
focus, is irregularly refracted, those rays passing through the 
vertical meridian of the cornea being brought to a focus much 
earher than those which fall through its horizontal meridian ; 
and therefore at the focus of the former the latter rays form 
a horizontal streak of light. The intermediate or oblique 
meridians will probably be of regularly intermediate refracting 
power. 

The interval between the foci of the two principal merid- 
ians is called the focal interval, and is a measure of the 
astigmatism. 

The accompanying diagram (Fig. 22), after Bonders, will 




Fig. 22. 

assist in the understanding of the course of a pencil of rays 
after they have passed through an astigmatic cornea, those 
rays belonging to the horizontal and vertical meridians being 
chiefly considered. 

At A neither vertical (v, v') nor horizontal (//, h') rays have 
yet been united at their foci, but the vertical rays are the 
nearest to their focus ; and therefore the appearance which the 
pencil of rays would give, if caught here on an intercepting 
screen, is an oval with its long axis horizontal. At B the 
vertical rays have met at their focus, but the horizontal rays 
not as yet at theirs, and the result is therefore a horizontal 
straight line. At C the vertical rays are diverging again from 
5 



58 DISEASES OF THE EYE. 

their focus, and the horizontal rays have still not come to 
theirs. At D the same conditions exist, only a little further 
on, where the one set of rays is diverging, the other still 
converging, but each at the same angle ; hence the shape of 
the figure is round. At F the horizontal rays have met, and 
the result is a vertical straight line. At G both sets of rays 
are divergent, and the figure is an oval, with the long axis 
perpendicular. 

There are various kinds of regular astigmatism, according 
to the position of the two principal foci, with reference to the 
retina, as follows : 

I. Simple Hypermetropic Astigmatism. — When the focus 
(V, Fig. 23) of the vertical rays is situated on the retina (em- 





FiG. 23. Fig. 24. 

metropia in that meridian), while that (H) of the horizontal 
rays lies behind the retina (hypermetropia in that meridian). 

2. Compoiimi Hypermetropic Astigmatism. — When the foci 
of both sets of rays is behind the retina, that (H, Fig. 24) of 
the horizontal rays further back than that (V) of the vertical 
rays. 

3. Simple Myopic Astigmatism. — When the focus (H, Fig. 
25) of the horizontal rays is situated on the retina (emme- 
tropia in that meridian), while the focus (V) of the vertical 
rays is situated in front of the retina. 

4. Compound Myopic Astigmatism. — When the foci of both 
sets of rays are situated in front of the retina, but further for- 
ward in the case (V, Fig. 26) of the vertical rays. 



ASTIGMATISM. 



59 



5. Mixed Astigmatisin. — When the focus (H, Fig. 27) of the 
horizontal rays falls behind the retina (hypermetropia in that 
meridian), and the focus (V) of the vertical rays in front of 
the retina (myopia in that meridian). 





YiG. 25. 



Fig. 26. 



Symptoms of Astigmatism. — We may conclude that an 
individual is astigmatic if he sees horizontal (or vertical) lines, 
such as the horizontal portions of Roman capital letters, or 
the horizontal lines in music, or the horizontal rays in Snellen's 
sunrise figure (see end of this book) distinctly, while the ver- 
tical (or horizontal) lines seem indistinct. W'e have such a 
complaint, for example, when the retina is situated at the focus 
of the parallel rays passing through 
the vertical meridian of the cornea. 

Suppose an eye to be emmetropic 
in the vertical meridian, and ametro- 
pic in the horizontal meridian : we 
must first consider how a point will 
be seen by such an eye. The rays 
of light emitted from the point and 

passing through the horizontal meridian will not be brought 
to a focus on the retina, but will produce a blurring of the 
retinal image of the point at each side ; while the vertical rays 
will unite on the retina, and consequently the point will appear 
distinctly defined above and below. 

A line may be regarded as a number of points, and in order 
to understand how lines will be seen by an astigmatic eye, 




Fig. 27. 



6o DISEASES OF THE EYE. 

such as the above, it is only necessary to arrange a number of 
points in vertical and horizontal lines — as at a and b in figure 
28. It is evident at once from mere inspection that the 
horizontal line will appear distinct, because the rays which 
diverge from each point of the latter in a vertical plane — /. e., 
at right angles to the direction of the line — are brought to a 
focus on the retina ; while those rays diverging in a horizontal 
plane, although not meeting on the retina, do not render the 
picture of the line indistinct, because the diffusion images re- 
sulting from them exist in the horizontal direction, and con- 
sequently cover or overlap each other on the line, and therefore 
are not seen and do not confuse the sight. At the ends of the 
line only (/;, Fig. 29) do the diffusion images cause a fuzziness 



Fig. 28. Fig. 29. 

or make the line seem longer than it is. In this case a verti- 
cal line (a^ Figs. 28 and 29) seems indistinct, because, the 
horizontal meridian being out of focus, the diffusion images 
existing in that direction are very apparent, as they do not 
overlap. On the other hand, in order to see a vertical stripe 
accurately, it is necessary only that the rays diverging in a 
horizontal plane should have their focus on the retina ; and, 
therefore, if an individual can only see vertical lines distinctly 
at six meters, we know that his eye is emmetropic in the hori- 
zontal meridian, and probably myopic in the vertical meridian. 
We do not, however, hear this complaint as often as might be 
expected, because simple astigmatism is not so common as one 
or other of the compound forms. 



ASTIGMATISM. 6i 

Astigmatic people do not generally see very distinctly, 
either at long or at short distances. 

Even in hypermetropic astigmatism the book is very often 
brought close to the eyes, in order, by increasing the size of 
the retinal image, to make up for its indistinctness. 

Astigmatic individuals frequently suffer much from head- 
ache, due to constant effort to see distinctly, and we cure the 
headache when we correct the astigmatism. 

It has been stated that epilepsy, if not capable of being 
produced by refractive errors, especially astigmatism, in per- 
sons with stable brains, may sometimes have such errors as 
its exciting cause where there is already a predisposition to 
the disease. 

All these signs and symptoms appertain more to the rather 
high degrees of astigmatism. Slighter degrees may cause no 
annoyance beyond some indistinctness of vision ; and, indeed, 
slight degrees of hypermetropic astigmatism often pass un- 
noticed until late in life, when the accommodation begins to 
fail. 

We are often led to suspect and to seek for astigmatism 
when, in examining the refraction with spheric glasses, we 
are able to bring about some improvement of vision, but can- 
not obtain normal V. with any glass, while there is no organic 
disease to account for the defect. Also, if, in examining with 
spheric glasses, we find V. benefited equally by several glasses 
of considerable difference in power, even, perhaps, by convex 
as well as by concave glasses. 

The ophthalmoscope affords us an admirable means of 
diagnosing astigmatism and of determining its amount. Just 
as the astigmatic eye cannot see horizontal and vertical lines 
equally well at at the same moment, so is an observer unable 
to see both the vertical and horizontal vessels in the retina of 
the eye simultaneously, but must alter his accommodation to 
be able to see first the one set and then the other. 



62 DISEASES OF THE EYE. 

A comparison of the shape of the optic papilla, as seen in 
the upright and in the inverted images, also gives a clue to the 
presence of astigmatism. Inasmuch as the fundus oculi is 
very much magnified in the upright image by the dioptric 
media through which it is seen, and as this enlargement is 
greater in the direction of the meridian of shortest focus 
(meridian of highest refraction), which is most commonly the 
vertical meridian, a circular object, such as the papilla, will 
seem to be of an oval shape with its long axis vertical. But 
in the inverted image, in the meridian of highest refraction, the 
image lies nearer the convex lens than in the meridian of low- 
est refraction, and hence is much less magnified in the former 
than in the latter meridian ; and here, consequently, the round 
optic papilla is seen as an oval with its long axis horizontal. 
Sometimes the papilla is really of an oval shape, and not 
round, and then the diagnosis is readily made by observing 
that in one image it is seen as an oval, while in the other 
image it is circular. Care must be taken in the indirect 
method not to hold the lens obliquely, as this would be suffi- 
cient to make a circular disc appear oval, the long axis of the 
oval being in the direction of the axis around which the lens is 
rotated. The determination of the degree of astigmatism can 
also be accomplished with the ophthalmoscope, and will be 
treated of in the next chapter. 

The Estimation of the Degree of Astigmatism and Its 
Correction. — It is evident that to correct astigmatism the 
ordinary spheric lenses would be of little use, for they affect 
the refraction of the light passing through them equally in 
every direction. We employ, therefore, what are termed 
cyhndric lenses, being sections of cylinders parallel to their 
axes, which refract light in one direction only — viz., that cor- 
responding to their curvatures and at right angles to their 
axes. The rays which pass through these lenses in a direc- 
tion corresponding to their axes are not refracted, but pass on 



ASTIGMATISM. 63 

without deviation, as they would do through a piece of plain 
glass. 

Although astigmatism is nowadays almost universally 
estimated by means of the ophthalmoscope or by the astig- 
mometer (see p. 66), yet in order to give the student a clear 
idea of the matter in the simplest way I shall here describe a 
subjective method for its estimation, while its objective esti- 
mation by aid of the ophthalmoscope will be treated of in the 
next chapter. 

Simple AstigmatisDi. — If, now, a case come before us in 
which we suspect astigmatism, we place Snellen's sunrise (vide 
diagram at end of book), or some such diagram, at six meters 
from the eye, the other eye being excluded, and inquire of the 
patient whether there be any line which he sees much more 
distinctly than the others, and can trace further toward the 
central point. If that be so we know that he is emmetropic 
in the meridian at right angles to that line, provided his accom- 
modation be at rest, and ametropic in the meridian correspond- 
ing to that line. 

In case the horizontal line below at each side be the distinct 
one, the eye is emmetropic in the vertical meridian, and pro- 
bably hypermetropic in the horizontal meridian, because the 
latter is generally that of least curvature. Consequently, a 
convex cylindric lens, held with its curvature horizontally 
(axis vertical) before the eye, will correct the defect. The 
highest convex cylindric glass which gives the patient the 
best possible distant vision will be the correcting glass. This 
is a case of simple hypermetropic astigmatism (As. H.). If 
the lens required be -j- 2 D Cyl, it would be As. H. 2 D ; and 
in prescribing for the optician we should write " -f 2 D Cyl. 
Ax. Vert." 

If the central vertical line be the distinct one, then emme- 
tropia exists in the horizontal meridian, and probably there- 
fore myopia in the vertical meridian ; and a concave cylindric 



64 DISEASES OF THE EYE. 

lens, held before the eye with its curvature vertical (axis hori- 
zontal), will correct the defect. The lowest concave cylindric 
lens which gives the patient the best possible distant vision 
will be the correcting lens. This is a case of simple myopic 
astigmatism (As. M.). If the lens be — 2.5 Cyl., it would be 
As. M. 2.5 D ; and for the optician we should write " — 2.5 
D Cyl. Ax. Horiz." 

I advise the reader to make now a few experiments for 
himself with cylindric lenses, by means of which he can pro- 
duce artificial astigmatism in his own eye. Let him place 
Snellen's sunrise figure (end of this book) opposite his eye at 
a distance of about four to six meters. If he now hold a 
-\~ i.o Cyl. before his eye, with its axis horizontal, it gives a 
myopia of one D to the vertical meridian of the eye, while the 
horizontal meridian remains emmetropic ; and consequently he 
will see the central vertical line of the diagram distinctly, 
while the horizontal lines will be indistinct. By placing a — i .0 
Cyl. with its axis vertical before the eye, in addition to the 
-|- 1.0 Cyl, the artificial astigmatism produced by the latter is 
corrected, and the whole diagram becomes distinct. Every 
other kind and degree of astigmatism can be similarly repre- 
sented by lenses and similarly corrected. 

Compound Astigniatism. — If no line be very distinctly seen, 
then we may commence our examination with Snellen's dis- 
tance test-types, and test in the 
ordinary way with spheric lenses 
until we find that one which gives 
H. 4 D + H. I D ^|-^g |3gs|- distant vision. This we 
place in a spectacle frame before 
the eye, and proceed, as already 
explained, to ascertain the meridians of greatest and least 
curvature of the cornea. If the spheric lens be -f 4 D, and 
with it the horizontal lines in the sunrise diagram be the most 
distinct, then the vertical meridian is shown to be corrected, 



H. 4D 



ASTIGMATISM. 65 

and the eye is probably still' hypermetropic in the horizontal 
meridian, and requires a -{- cylindric lens with its axis vertical, 
in addition to the spheric lens, to correct the entire defect. 
Suppose this cylindric lens be found to be -p i D Cyl., then 
the H. in the horizontal meridian will be shown to be five D, 
and the astigmatism to be one D. 

The latter noted down would be of little practical value, 
and therefore we prefer to write in our note-books the factors 
of the astigmatism, thus : *' H. 4 D -f As. H. i D Horiz." ; 
or, as for the optician, *' -f 4 D Sph. O -f i D Cyl. Ax. Vert.'"^ 
This is compound hypermetropic astigmatism. 

In an analogous way we examine for compound myopic 
astigmatism, in which every meridian is myopic, but the ver- 
tical more so than the others. 

Mixed Astigmatism. — Lastly, we come across cases in which 
both concave and convex spheric lenses produce a certain 
amount of improvement, but neither gives 
full vision. Placing, then, one or other 
before the eye in the spectacle frame, the 

examination is proceeded with by aid of H. D 5 

Snellen's sunrise. We ascertain, for ex- 
ample, what is the lowest conca\'e spheric 
lens which will bring out one horizontal ray distinctly. Let 
this be — 3D; we have then myopia of three D in the vertical 
meridian. Now, having removed the — lens, we find what is 
the highest convex lens which will bring out one vertical line 
distinctly. Let it be + 5 D ; this indicates hypermetropia of 
that amount in the horizontal meridian. We may correct 
such a case in either of two wa)'s : {a) by a Sph. — 3D, 
which will correct the vertical meridian, but will increase the 
hypermetropia in the horizontal meridian by three D, making it 
eight D, which can then be corrected by combining a cylindric 

* The sign 3 indicates " combined with." 



66 DISEASES OF THE EYE. 

lens of + 8 D, axis vertical, with the above spheric lens ; 
{b) by a spheric -j- 5 D, which will correct the horizontal 
meridian, but will increase the myopia in the vertical meridian 
to eight D, necessitating the combination of a — Cyl. lens of 
that number with the + 5 D Sph. For reading, writing, etc., 
an over-correction of the horizontal meridian with -|- 8 D Cyl., 
thus rendering the eye myopic three D in every meridian, and 
enabling the patient to read at or near his far point, might be 
the most suitable arrangement. 

As it is necessary, in order to test the degree, etc., of astig- 
matism accurately, that the accommodation be at rest, it is 
desirable, before the examination for any of the hypermetropic 
forms, to instil atropin into the eye. 

Measurement of the Degree of Astigmatism by the 
Astigmometer. — This is one of the most rapid and satisfac- 
tory methods of determining both the degree of astigmatism 
and the position of the meridians of greatest and least refrac- 
tion. It is based on the principle of the ophthalmometer, an 
instrument by which Helmholtz demonstrated the changes in 
the curvature of the lens during accommodation. 

The cornea reflects images of objects in the same manner 
as a convex mirror, and the smaller the radius of curvature 
the smaller will the image of any given object be. It is easy 
to calculate the radius of curvature of the cornea, knowing 
the size of the object, the distance of the object from the 
cornea, and the size of the corneal image. The only difficulty 
lies in the measurement of this image ; and it has been found 
that the best method of effecting this is to double the image 
by looking at it through a double refracting prism, and then 
to alter the strength of the prism until the two images just 
come into contact. When this has taken place a displacement, 
equal to the size of the image, has been produced. The amount 
of displacement, and hence the size of the image, can easily 
be calculated. 



ASTIGMATISM. 



67 



The astigmometer was first brought into practical use by 
Javal and Schiotz. The instrument which is in use at the 
National Eye and Ear Infirmary, and which has proved of great 
service, is a modification of Javal's, made by Kagenaar, of 




Fig. 30. 



Utrecht. In order to measure the degree of astigmatism by 
it, we do not require to know the radius of curvature of the 
cornea, but merely to find out the difference in refracti\'e power 
between the meridians of greatest and least curvature, and 



68 DISEASES OF THE EYE. 

this the astigmometer enables us to do in a few seconds with- 
out any calculation. 

It consists (Fig. 30) of a telescope (/) containing a double 
refracting prism between the object glasses, and two reflectors 
{k and /), which are movable on an arc (;;/), which is fixed to 
the telescope tube. The latter turns on its own axis, and en- 




FiG. 31. 



ables the arc to be placed in any meridian, its position being 
indicated on a graduated circle (^g). The patient places his 
chin on the rest d, and looks into the tube at/, the eye which 
is not under observation being covered by the disc e. The 
surgeon then looks through the telescope at u, turns the arc 
in into a horizontal position, and observes the corneal images 
of the reflectors, which he gets into focus. He then moves 
the reflectors until the central images just 

Bcome into contact ; the four images will then 
occupy the relative positions shown in figure 
31. The arc is then rotated into the vertical 
meridian, and if the curvature of the cornea be 
Fig. 32. the same as before, the central images will still 

appear to be in contact. But if the radius of 
curvature be smaller, the intervals a to b and a' to // will 
diminish, and consequently the central images will overlap, 
as in figure 32, each step of a' representing a difference of 
one D. So that in this case there would be an astigmatism 
of two D, and the greatest refraction would be in the vertical 
meridian. 



ASTIGMATISM. 69 

It is generally best to begin with the arc in the horizontal 
meridian. If the axes of the meridians of greatest and least 
curvature are oblique, then the images will not lie in one line, 
and the arc must be turned until they do so. An index which 
moves on the circle g gives the position of the axes. It will 
be seen from the above description that the astigmometer 
merely registers the amount of astigmatism, but does not en- 
able us to estimate the refraction of the qvq. Moreover, it is 
the corneal astigmatism alone which is determined, and it will 
be found that in the vast majority of cases this is the only 
astigmatism present. 

Lental Astigmatism. — Disturbances of vision due to astig- 
matism often make their appearance for the first time at middle 
age or even later, and are then apt to be mistaken for am- 
blyopia. In such cases the cornea has been astigmatic all 
through life, but the defect has been masked by a compensat- 
ing astigmatism of the crystalline lens, produced by an un- 
equal accommodative contraction of the ciliar}' muscle. When, 
now, as life advances the amplitude of accommodation dimin- 
ishes, the power of the ciliary muscle to produce this acdve 
compensatory lental astigmatism also diminishes, and finally 
disappears, and consequently the corneal astigmatism comes 
to the front ; or, in astigmatic individuals, the astigmatism may 
alter in degree at this time of life. Under atropin, too, as- 
tigmatism may appear, the existence of which was not pre- 
viously known. This is termed active, or dynamic, lental 
astigmatism. 

Passive, or static, lental astigmatism is due to irregularity 
in the shape of the unaccommodated lens, and gives rise to 
disturbances of vision similar to those caused by corneal 
astigmatism, or it increases existing corneal astigmatism, or it 
more or less completely compensates the corneal astigmatism. 
It has no clinical importance which does not attach to corneal 



70 DISEASES OF THE EYE. 

Irregular Astigmatism. 
In irregular astigmatism the refraction of the eye differs 
not only in different meridians of the eye, but even in different 
parts of one and the same meridian. It is frequently due to 
irregularities on the surface of the cornea, the result of former 
ulcers, and also sometimes to irregular refracting power in 
different parts of the crystalline lens. It cannot be corrected. 
Its presence can be detected by the distortion and irregular 
movement of the disc when the lens is moved during the in- 
direct method of examining with the ophthalmoscope, and 
also by the irregular shadow in retinoscopy. In some cases 
there is a certain amount of regular astigmatism combined 
with it, correction of which may improve the vision. 

Anisometropia * 
means a difference in the refraction of the two eyes, one being 
myopic, hypermetropic, or astigmatic, while the other is emme- 
tropic or ametropic in a way different from its fellow. So 
long as the difference in refraction is but slight (say one D or 
1.5 D), it is generally possible to give the correcting glass to 
each eye. When the difference is considerable it is often 
impossible to fully correct each eye, because, binocular vision 
having never really existed, the patients are unable to tolerate 
the presence of a clear image on each retina. We must then 
be content with correction of the least ametropic eye, or of 
that one which has the best vision ; or we may partially cor- 
rect the most ametropic and fully correct the least ametropic 
eye. Each such case must be dealt with as it permits. 



a,priv. ; laog, like ; fJtrpov, a measiire. 



PRESBYOPIA. 



71 



ANOMALIES OF ACCOMMODATION. 

Presbyopia. 
This is a diminution in the amplitude of accommodation 
which commences at an early age, and is due solely to natural 
changes taking place slowly in the crystalline lens. It might 
not, therefore, strictly speaking, be considered as an anomaly. 
The power of accommodation com.mences to diminish in early 



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childhood, the near point beginning then to recede from the eye. 
Bonders it was who first discovered this fact, and ascertained 
the laws which govern the progressive decrease of accommo- 
dative power. He designed the accompanying diagram (Fig. 
33), which illustrates the decrease from the tenth year of age, 
and indicates the amplitude of accommodation at different 
acres. 



72 DISEASES OF THE EYE. 

The numbers along the upper horizontal line refer to the 
ages ; those along the left-hand perpendicular line to the 
dioptrics. The curve r r shows the refraction of the eye when 
in a state of rest. This is unchanged until the fifty-fifth year, 
when it begins to diminish ; the emmetropic eye then becoming 
hypermetropic, the hypermetropic eye more hypermetropic, 
and the myopic eye less myopic. The curve / / shows the 
positive refracting power of the eye, corresponding to the 
punctum proximum, and its gradual diminution as life ad- 
vances, and how at the age of sixty-five it becomes even less 
than the minimum refraction in former years. The two curves 
meet at the age of seventy-three, and then all power of accom- 
modation ceases. The number of dioptrics included between 
the two curves on the vertical line corresponding to any given 
age represent the amplitude of accommodation at that age — 
e, g., at thirty years of age the amplitude is seven D ; at fifty 
years it is only 2.5 D. The amplitude of accommodation is 
the same at the same age in all forms of ametropia, as well as 
in emmetropia. 

The cause of presbyopia lies chiefly in a progressive change 
in the crystalline lens, which becomes less elastic and more 
homogeneous in its different layers, and refracts light less 
strongly than before. In more advanced life diminished 
energy of the ciliary muscle probably becomes a second factor 
in the production of presbyopia. 

The near point gradually recedes from the eye until it 
reaches a distance beyond that at which the person usually 
reads, writes, sews, etc. Employments of this kind then be- 
come difficult, because the retinal images are too small to be 
clearly discerned, owing to the increased distance at which 
the work must be held from the eye ; and in order to make 
up for this smallness of the images, the individual is often seen 
to improve their brilliancy by procuring stronger light. 

Presbyopia is usually said to be present when the near 



PRESBYOPIA. 



73 



point lies at more than 22 cm. from the eye, and we correct it 
by giving such a convex glass for reading, etc., as will bring 
the near point back to 22 cm. Now, in order to see at that 
distance, a positive refracting power (/) of C^-^ ==) 4.5 D is 
necessary, and if the eye have not so much positive refraction, 
a convex glass must be given to it of such power as will bring 
/ up to 4. 5 D ; and this lens is the measure of the presbyopia. 
At the age of forty (vide Bonders' diagram. Fig. 33) the eye 
possesses a positive refraction of just 4. 5 D ; and therefore 
from this age presbyopia (r.piff^uc, an old man ; ^0) is said to 
commence in emmetropic eyes. The presbyopia, then, is equal 
to the difference between the positive refracting power possessed 
by the eye and 4.5 D, and the number thus found is the cor- 
recting glass for the presbyopia. 

It is important for the patient's comfort that in prescribing 
glasses for presbyopia, if there be any hypermetropic astigma- 
tism present, it should be corrected by the suitable -f cylinder 
lens added to the spheric glasses. 

The following table indicates the presbyopia of the emme- 
tropic eye : 



Age. 


/ required. 


/ existing. 


Presbyopia. 


40 


4-5 


4-5 





45 


4-5 


3-5 


I.O 


50 


4-5 


2-5 


2.0 


55 


4.5 


1-5 


30 


60 


4-5 


0-5 


4.0 


65 


4.5 


0.25 


4.25 


70 


4-5 


-1.0 


5-5 


75 


4.5 


-1-75 


6.25 


80 


4-5 


-2.5 


7.0 



It is hardly necessary to point out that presbyopia comes 
on at a much earlier age in hypermetropes than in emmetropes ; 
while in myopes its advent is postponed ; or, in the higher 
degrees of myopia, it may not come on at all. The hyper- 



74 DISEASES OF THE EYE. 

metrope of three D would be presbyopic at the age of twenty- 
seven ; because, in order to arrive at the 4. 5 D of positive re- 
fraction required, he must have an amplitude of accommoda- 
tion of (3 D -f 4.5 D) 7.5 D, and this he has only up to that 
age {^inde Fig. 33). 

The myope of 4.5 D can get along until something over 
sixty years of age without any glass for reading {inde above 
table). At sixty-five, if he were emmetropic, he would have 
presbyopia of 4.25 ; consequently he will now require a -f- 
glass of only 0.25 D. 

Presbyopia must not be mistaken for slight paralysis of ac- 
commodation. They are distinguished by the fact that in the 
former the amplitude of accommodation corresponds to the 
age of the patient as given in Bonders' table. 

Paralysis of Accommodation. 

This may be partial or complete, and one or both eyes may 
be affected. It is usually combined with paralysis of the 
sphincter iridis (mydriasis), and the condition is then called 
ophthalmoplegia interna ; but it is also seen without paralysis 
of the sphincter, and either alone or with paralysis of some 
of the orbital muscles supplied by the third pair — rarely with 
paralysis of the external rectus. 

TJie symptoms are similar to those of presbyopia, and give 
inconvenience to the patient according to the state of his re- 
fraction. If he be emmetropic, his distant vision continues 
good, while his vision for near work is much impeded. If he 
be hypermetropic, as he requires his accommodation for distant 
objects, vision for distance is interfered with, and still more so 
vision for near objects. If he be myopic, vision is less affected 
than in either of the other forms of refraction ; indeed, if he 
be very near-sighted, being able to see near objects at his far 
point, he may suffer little or no inconvenience. 

Micropsia is a common symptom in cases of partial paralysis 



PARALYSIS OF ACCOMMODATION. 75 

of accommodation, and is due to the fact that, while the retinal 
image is unaltered in size, the great effort of the defective ac- 
commodation giv^es the sensation of the object being much 
nearer to the eye than it really is. 

Causes. — The most common cause of paralysis of accommo- 
dation is the action of atropin ; but it is also the result of or 
is attendant upon various diseases. It is one of the symptoms 
of paralysis of the third nerve ; it may be due to exposure to 
cold ; or it may depend upon syphilis, syphilitic periostitis at 
the sphenoid fissure, syphilitic gumma, or syphilitic inflamma- 
tion of the nerve itself. 

In cases of double paralysis of accommodation a central 
cause must often be looked for. Paralysis of accommodation 
and mydriasis are sometimes forerunners, by many years, of 
serious mental derangement. 

Diphtheria is a frequent cause of paralysis of accommoda- 
tion, usually without, but sometimes with, mydriasis. The 
onset occurs most commonly some weeks after the throat 
affection, which need not have been of a severe character. 
Indeed the faucial attack may have had no apparent diph- 
theritic character, and may have been so slight as almost to 
have escaped the notice of the patient. The lesion in these 
cases is probably a nuclear one, and the evidence points to 
miliary extravasations of blood in the floor of the fourth 
ventricle ; but there are those who hold that the paralysis is 
due to a poison ; that it is a toxic paralysis. 

During the recent epidemics of influenza (la grippe) cases of 
paralysis of accommodation were recorded, occurring, some of 
them, during the acute stage and others during convalescence. 
One went on to bulbar paralysis, and ended fatally ; the others 
recovered. 

Paralysis of accommodation in middle life may be due to 
diabetes, and should make us suspicious of the presence of 
this disease. 



76 DISEASES OF THE EYE. 

Blows on the eye are apt to cause paralysis of accommoda- 
tion, usually with mydriasis. 

Tlie treatment depends, of course, upon the cause of the 
paralysis. The instillation of a one per cent, solution of sul- 
phate of e serin or of muriate of pilocarpin may be employed 
in all cases, and will at least produce temporary improvement 
of sight ; but it can hardly be said to assist in the cure, except, 
perhaps, in slight diphtherial cases. lodid of potassium and 
mercury are indicated in syphilitic cases, and iodid of potas- 
sium and salicylate of sodium in rheumatic cases. The prog- 
nosis in these cases must be very guarded, as it often happens 
that recovery does not take place. Where cure does not re- 
sult, the patient may be enabled to make better use of his eye 
or eyes by means of a convex glass or spectacles ; but in this 
matter each case must be dealt with for itself — no general rule 
can be laid down. 

In diphtheric cases a general tonic treatment, especially 
iron, is indicated ; and here the prognosis is invariably favor- 
able. 

Accommodative Asthenopia 

has been already treated of under the head of Hypermetropia 

(P- 39)- 

Spasm of Accommodation. 

Spasm or cramp of accommodation, in connection with 
hypermetropia and myopia, has already been referred to. A 
few cases of acute spasm of accommodation have been 
reported.* Occurring in an emmetropic or slightly hyper- 
metropic eye, such a spasm produces apparent myopia. In 
some of the cases there was no assignable cause for the spasm, 
in some it was due to overwork, and in one to trauma of the 
cornea. The treatment is a lengthened course of atropin locally. 



*A, von Graefe, Archiv f. OphthaL^ Vol. ii, pt. 2, p. 308; Liebreich, 
Archiv f. Ophthal., Vol. iii, pt. I, p. 259; C. E. Fitzgerard, Trans. Ophthal. 
Soc, Vol. V, p. 311. 



CHAPTER III. 

THE OPHTHALMOSCOPE. 

Although the dioptric media of an eye are perfectly clear 
and normal, yet no detail of its fundus can be discerned by the 
unaided eye of an observer who looks through the pupil, the 
latter being for him merely a dark opening. The reason of 
this is that these dioptric media are composed of a system of 
convex lenses. To explain : Suppose the inside of a small 
box {inde Fig. 34) to be blackened, and on its floor some 




Fig. 34. 

printed letters fastened, and a hole cut in the lid, which is 
then replaced, it will be found that, by aid of a lighted candle 
and with a little experimentation, the letters may be read 
through the aperture. The rays passing from the light L into 
the box through the aperture illuminate the opposite surface, 
and from this surface the rays a, b, and others, pass out again 
through the opening, and some of them fall into the observer's 
e}'e at E. 

But if, in order to make this box represent an eye more 
accurately, we place a convex lens immediatel}^ within the 

77 



78 



DISEASES OF THE EYE. 



aperture, the course of the rays is altered. All the rays pass- 
ing into the box (Fig. 35) from L are brought to a focus on its 
opposite side at ;// by the convex lens ;/, and, according to the 
optic law of conjugate foci, all the rays passing out from the 
box meet again at the source of light, Z, and hence none of them 



Ja3 



Fig. 35. 

can be received by the eye {a) of the observer ; nor can this 
eye be placed in any position where it could catch any of these 
rays, for if it be placed anywhere between the aperture and Z, 
it would cut off the light passing from L into the box. 

Helmholtz' s Ophthalmoscope. — If the eye of the observer could 
itself be made the source of light, the difficulty would be solved ; 




Fig. 36. 

and, practically, this is what Helmholtz accomplished with his 
ophthalmoscope in the year 1 8 5 1 . The instrument he invented 
was composed of a number of small plates of glass {0, Fig. 
36), from which light from L was reflected into the eye (Z), and 
thus the fundus of the latter illuminated. From in rays pass 
back again by the same course to the ophthalmoscope, 



THE OPHTHALMOSCOPE. 79 

some being reflected back to L ; but some, passing through 
the ophthalmoscope, and falling into the observer's eye placed 
close behind the instrument at a, form in it an image of in. 

Modern OpJitliahnoscope. — For the original ophthalmoscope 
of Helmholtz a concave mirror of 20 cm. focal length, with a 
central opening, has been substituted. This mirror [0, Fig. 
37) throws convergent rays into the eye {E\ and these, being 
made more convergent by the refracting media, cross in the 
vitreous humor, and light up part {a b) of the fundus. From 
every point of this illuminated surface rays are reflected back 
again out of the eye. If the latter be emmetropic, the rays 
from any one point become parallel on leaving it, and some of 




Fig. 37. 

these parallel rays, passing through the aperture (c) of the 
ophthalmoscope, fall into the observer's eye, and if it be em- 
metropic, are brought to a focus on its retina — the rays from 
in at in' , those from x at x' , and those from y at j'' — and thus 
an image of the part x my is formed on the observer's retina. 
The foregoing method of examining with the ophthalmo- 
scope is called the direct method, or the examination of 
the upright image. By it the various parts of the fundus 
are seen in their natural positions, but much enlarged (about 
I 5 diameters in the emmetropic eye), and it is consequently 
very valuable for examining minute details. 



8o DISEASES OF THE EYE. 

It is necessary for this method that the surgeon should ap- 
proach his eye as close as possible to the eye under examina- 
tion, in order to receive as much of the light coming out of 
it as possible. 

It is also necessary for this method that the accommodation, 
both of the surgeon's and of the patient's eye, be at rest, as 
otherwise the rays coming from the latter cannot form an 
image on the retina of the former, at least if both be emme- 
tropic. 

If the patient exert his accommodation, the rays will, on 
leaving his eye, become convergent instead of parallel, and 
falling into the surgeon's eye, will be brought to a focus in 
front of his retina. If the surgeon exert his accommodation, 
the parallel rays from the patient's eye will, likewise, on falling 
into his (the surgeon's) eye, be brought to a focus in front of 
his retina. And if both patient and surgeon accommodate, 
the focus of the rays from the patient's fundus oculi will, of 
course. He still further in front of the surgeon's retina. The 
patient's accommodation can be relaxed by making him gaze 
at the black wall behind the surgeon's head, or his accommo- 
dation may be paralyzed with atropin. But atropin should 
never be used unless absolutely necessary, owing to the in- 
convenience it causes the patient. 

Voluntary relaxation of the accommodation on the part of 
the surgeon is often a matter of much difficulty to beginners. 
The ciliary muscle not being a voluntary muscle is not under 
our direct control, and can be influenced only in a secondary 
way through the convergence of the optic axes, for this 
convergence is regulated by voluntary muscles (the internal 
and external recti), and is intimately associated with the 
effort of accommodation. With parallel optic axes our ac- 
commodation is relaxed ; therefore, when we want to relax 
our accommodation, we produce parallelism of our optic axes. 
This sounds easy enough ; yet, when the beginner approaches 



THE OPHTHALMOSCOPE. 8i 

his eye close up to that of his patient, the knowledge that he 
is so close to the object he wishes to see renders the accom- 
plishment of this parallelism and relaxation of accommodation 
very difficult to man\'. 

It is not easy to teach another person how to relax his ac- 
commodation, but the folloAving- hint ma}' be of use : Take a 
printed page, and hold it at the ordinary reading distance, so 
that the type may be clearly seen ; then gaze vacantly at it, so 
that the t}'pe ma\' become indistinct. The accommodation is 
now relaxed, and the act is accompanied by a peculiar sensa- 
tion in the e\'es. A\'hen examinino- in the erect imafre. cause 
this same sensation to take place ; and it ma}' be assisted, if, 




with the e}-e Avhich is not in use, the black wall behind the 
patient's head be gazed at. 

The indirect method, or the examination of the in- 
verted image, is employed in order to obtain a more general 
view of the fundus than the direct method admits of. 

In addition to the ophthalmoscope a convex glass (/, Fig. 38) 
of about 14 D is here used. The latter is held about ten cm. 
from the e}'e {£) under examination, while the observer throws 
the light through it into the e}'e. In passing through the lens 
the ra}'s are made convergent, and this convergence is in- 
creased b}' the refracting media, so that the ra}^s cross in the 
vitreous humor, and light up a portion of the fundus oculi. 
7 



82 DISEASES OF THE EYE. 

From any points a and b of this illuminated place pencils of 
rays pass out again from the eye, and becoming parallel, pass 
through the lens and are united by it at a' b' ; and thus a real 
inverted image is formed of the part a b, which image may be 
seen by the observer whose eye is placed behind 0. The 
stronger the lens, /, the more convergent must rays from the 
examined eye be made ; and consequently the closer must a^ b' 
be to each other, and the smaller and brighter must be the 
image formed. The weaker the lens, /, the larger and less 
brilliant is the image, and the less annoying to the surgeon are 
the reflexes from the surfaces of the lens. 

In examining by the indirect method, the observer first places 
the upper edge of the ophthalmoscope to his right supra-orbital 
margin, and taking care that he is looking through the central 
opening of the mirror, he reflects the light of the lamp into 
the patient's eye at a distance of about 50 cm. A red glare 
from the fundus will then be seen in the pupil. Keeping the 
pupil illuminated, the convex 14 D, held between the forefinger 
and thumb of the surgeon's left hand, is brought up in front 
of the patient's eye, and kept there in the perpendicular position, 
the surgeon steadying this hand with the tip of the little finger 
on the patient's forehead. The convex glass is now removed 
just far enough from the patient's eye to cause the margin of 
the pupil to disappear out of the surgeon's field of vision. 
The observer then ceases to look into the eye, and fixes his 
gaze on the convex glass, when the inverted image of the 
fundus should at once become visible — and will seem to be 
situated in the convex lens, although it really is in the air some- 
what this side of the lens. 

The diagram (Fig. 39) serves to illustrate the effect of inver- 
sion of the image. 

The left eye is seen in the upright image in the left-hand 
picture, while the same eye is seen in the inverted image in 
the right-hand picture. In the diagram the two images are 



THE OPHTHALMOSCOPE. 



8.-. 



of the same size for the sake of convenience ; although, of 
course, in realit\- the upright image is much larger than the 
inverted image. ^loreover, it should not be supposed that 
nearly the whole fundus oculi, as here represented, can be taken 
in at one view of the ophthalmoscope. The portion visible 
with the ophthalmoscope at one moment, even in the inverted 
image, is small ; so that it is necessary to examine the different 
regions in detail in order to become acquainted with their 
condition. 

The reflex from the surface of the cornea gives a good deal 
of anno}-ance to every beginner. It cannot be done awa}' with ; 
but as it moves in the opposite du'ection to amotion of the ob- 




FiG. 39. 



ject lens, it is possible to see past it. The reflections from the 
convex object-lens are also extreme!}- anno}-ing, but may be 
removed to a o-reat extent from the line of sio-ht bv a slio-ht 
rotation of the lens on its axis. If a very high convex lens 
(say -}- 20 D) be used, the reflections from it are more disturb- 
ing than from a lower number (sa\- — 14 D). 

To examine the optic ncri-c the surgeon sits in front of the 
patient, and directs him to turn his eye somewhat to the nasal 
side, and slightly upward ; because the papilla is situated 
about 15^ to the inner side of the posterior pole of the eye, 
and about three degrees above it. For instance, if the left eye 
be examined the patient is to direct his gaze, without turning 



84 DISEASES OF THE EYE. 

his head, to the right and a httle upward, say toward the sur- 
geon's left ear. It is well always to seek out the optic papilla 
in the first instance, not only because it is so important a part 
of the fundus oculi, but also because, examining from it toward 
the periphery, we are the better able to determine the locality 
of any pathologic alteration. 

Should the patient not direct his gaze in such a way as to 
enable the surgeon to see the optic papilla or other desired 
region, it may be brought into view either by a motion of the 
surgeon's head in the opposite direction, or by a motion of the 
convex lens in the same direction, or by a combination of both 
these manoeuvers. 

The viacula hitea should then be examined. It may be 
seen by directing the patient to look straight at the hole of 
the ophthalmoscopic mirror, for it will then correspond with 
the macula lutea of the observer's eye. It is more readily 
seen in the inverted than in the upright image ; but its ex- 
amination is often very difficult, owing to contraction of the 
pupil produced by the strong light falling on so sensitive a 
portion of the retina, and by the reflections from the surfaces 
of the cornea and crystalline lens, which fill the area of this 
contracted pupil. It is, therefore, a better plan to direct the 
patient to look somewhat to the side of the eye under examina- 
tion — e.g., to the right side of the observer's forehead, if the 
right eye be under examination, and then, by motions of the 
convex lens, to bring the macula lutea into view. 

After this, the periphery of the fundus in every direction is 
to be examined by making the patient look upward, downward, 
to the right, to the left, etc. 

Estimation of the Refraction by Aid of the 
Ophthalmoscope. 
From what has been said with reference to the direct 
method of ophthalmoscopic examination, it will have become 



THE OPHTHALMOSCOPE. 85 

evident that this method affords a means for determining the 
refraction of the eye. 

At a httle distance from the observed eye, into which hght 
from the ophthalmoscopic mirror is thrown, the surgeon will 
be able to see some of the details of the fundus, if it be either 
myopic or hypermetropic ; but if it be emmetropic he will be 
unable to do so. The reason for this is that in myopia the 
rays coming out of the eye form an inverted image at the far 
point of the eye in the air, and this image can be seen by the 
observer who accommodates his eye for that point. In hyper- 
metropia, the rays coming out divergently from the eye pass 
into the observer's eye, and by an effort of accommodation on 




Fig. 40. 

his part he will see an upright image of the portion of the 
patient's fundus oculi from which they come. But in emme- 
tropia, inasmuch as the rays come out parallel, those from any 
two points (w, n, Fig. 40) at a short distance from each other 
in the fundus, on emerging from the eye diverge quickly from 
each other, and the observ^er a little way off (at A) receives 
none of them into his eyes, or obtains only an indistinct image 
or red glare. If he go very close to the eye he can see details. 
If, on the observer moving his head from side to side, the 
vessels, etc., of the observed fundus move with him, the case 
is one of hypermetropia, because the image is an erect one, 



86 DISEASES OF THE EYE. 

which is situated behind the plane of the pupil to which it is 
referred. If the vessels, etc., move in the opposite direction 
to that of the observer's head the observed eye is myopic, 
because there the image is inverted and in front of the pupil. 

For the quantitative determination of ametropia a refrac- 
tion ophthalmoscope is required. This instrument provides 
a number of convex and concave lenses, capable of being 
brought into position behind the sight-hole in rapid succession 
by a simple mechanism. 

It is necessary, in the first instance, that the surgeon be 
aware of the nature of his own refraction. 

If tlie surgeon be eimnetropic he can see the fundus oculi of 
an emmetrope in the upright image without any lens, pro- 
vided he go close enough, as the parallel rays coming from 
the examined eye will be focussed on his retina, because his 
eye is adapted for parallel rays. 

In order to see the fundus oculi of a hypermetrope without 
any effort of accommodation he must place such a convex 
lens behind his ophthalmoscope as will render the divergent 
rays coming from the patient's eye parallel before they pass 
into his eye. This lens is the measure of the patient's hyper- 
metropia, because it shows how many dioptrics the eye wants 
of being emmetropic ; or, in other words, so that the rays 
coming from it may be made parallel. The lens which makes 
the divergent rays coming from the patient's retina parallel, 
would also give to parallel rays passing into the eye such 
convergence that they would meet on the retina — /. r., it 
would correct the hypermetropia. 

The emmetropic surgeon can, of course, see the fundus oculi 
of a hypermetrope by the direct method without the correct- 
incr p;lass if he use his accommodation to overcome the diver- 
gence of the rays, and this is usually the case in the lower 
degrees of hypermetropia. The surgeon generally relaxes 
his accommodation according as he substitutes convex lenses 



THE OPHTHALMOSCOPE. 87 

for it, until he reaches the strongest lens with which he can 
distinctly see the fundus. This is the correcting lens. 

To see the fundus oculi of a myope the emmetropic surgeon 
must place a concave glass behind his ophthalmoscope, in 
order that the convergent rays coming from the observ^ed eye 
may be made parallel before they pass into his eye ; and the 
lozvcst concave lens which enables him to see the fundus oculi 
is the measure of the myopia, as showing by how many diop- 
trics it is in excess of emmetropia. 

The emmetropic surgeon cannot possibly see the fundus 
oculi of a myope without the correcting glass, as the rays are 
brought to a focus in front of his retina, and if he use his 
accommodation he merely makes them still more convergent. 
But by means of an effort of his accommodation he can see 
the myopic fundus with a lens which over-corrects the 
myopia, and hence the importance of selecting the iveakcst 
concave glass with which the fundus is distinctly seen. 

If the surgeon be ametropic, he may either correct his 
ametropia by wearing the suitable lens, and then proceed as 
though he were emmetropic, or else, and which is perhaps 
the better plan, he may add or subtract the amount of his 
ametropia from that of his patient's. For example : 

The Jiypcnnctropic surgeon^ of say three D, requires a -f lens 
of three D in order to see an emmetropic fundus oculi, this lens 
going altogether to correct his own defect. If, in order to 
examine the fundus of another eye, he require a + lens of 
six D, the examined eye must be hypermetropic three D, the 
other three D going to correct the surgeon's H. If he be able 
to see the fundus oculi under observation without any lens it 
shows that the eye has an excess of refraction corresponding 
to the want of refraction in his own eye — that is to say, it is 
myopic three D. If he require a concave two D, his want 
of refraction — his hypermetropia — is not enough by that 
number of dioptrics, and he has to do with an eye which is 



88 DISEASES OF THE EYE. 

myopic five D (3 D + 2 D). Again, if he can see the fundus 
distinctly with a -[- lens, say -|- i.o, which is less than his 
own correcting glass, this shows that the eye he is examining 
is myopic, but myopic to a lesser degree — in this instance by 
one D — than he himself is hypermetropic, and the examined 
eye here would be M. 2.0 D — /. e., 3.0 — i.o. 

If the surgco7t be myopic, say two D, he requires a — 2D 
to see the fundus of an emmetropic eye, this lens going wholly 
to correct his own ametropia. If he see the fundus with a 
— 7 D, the examined eye has M. 5 D, because two D have 
been used in correcting the surgeon's M. If he be able to 
see a fundus without any lens, the patient has H. 2 D, the 
want of refraction in the latter' s eye compensating exactly for 
the excess of refraction in the surgeon's eye. If he find it 
necessary to use a + l^J^s of seven D it will indicate that his 
excess of refraction is not able to make up for the defect of 
refraction in his patient's eye, and that the latter has H. = 9 D 
(2 D + 7 D). If he have to use a — lens, say — 1.0 D, 
which is less than his own correcting glass, this shows that 
the eye he is examining is hypermetropic to a lesser de- 
gree — in this instance by 1.0 D — than he himself is myopic, 
and the hypermetropia here would be 1.0 D — i. e., 2.0 
— I.o. 

TJie Existence and Degree of Astigmatism may be Determined 
ivitJi the Ophthalmoscope. — We know that astigmatism is present 
if in the upright image we see the upper and lower margins 
of the disc and the horizontal vessels well defined, while the 
lateral margins and the vertical vessels are blurred, or vice 
versa. Again, we know that astigmatism is present if in com- 
paring the shape of the optic disc in the upright and inverted 
images we find it to be an oval with its long axis perpendicular 
in the former, and with its long axis horizontal in the latter, 
showing that the refracting media are more powerful in the 
vertical than in the horizontal meridian. 



THE OPHTHALMOSCOPE. 89 

We may ascertain the kind and degree of astigmatism as 
follows : 

If in the upright image with relaxed accommodation Ave 
can see the retinal vessels in one meridian distinctl}-, while in 
order to see those in the opposite meridian a concave or 
convex lens behind the ophthalmoscope is required, we know 
that the case is one of simple myopic or hypermetropic astig- 
matism ; the emmetropic meridian being that at right angles to 
the vessels ^' seen without any lens, and the number of the lens 
indicating the amount of ametropia in the other meridian. 

If in the two principal meridians two concave lenses or 
two convex lenses of different strength be required, we have 
to deal with a case of compound astigmatism, m}-opic or 
hypermetropic ; the greatest error of refraction being in the 
meridian at right angles to that one, the vessels of which are 
made distinct by the strongest lens. 

If a concave lens be required to bring into distinct view the 
vessels in one meridian, while a convex lens is required for 
the opposite meridian, the case is one of mixed astigmatism. 
]\Iyopia exists in the meridian at right angles to that in which 
the vessels are brought into view b}* the concave lens, and 
hypermetropia exists in the opposite meridian. 

I would again impress upon the reader the absolute neces- 
sity of thoroughl}- relaxing his accommodation in all exami- 
nations in the upright image. Parah'sis of the patient's ac- 
commodation with atropin is necessaiy in most cases where 
accurac}' in the determination of the refraction with the oph- 
thalmoscope is required, and can hardly be done without in 
cases of hypermetropia and of h\-permetropic astigmatism, 
owing to the cramp of accommodation Avhich is almost ahvays 
present. 



*The vessels maybe regarded as lines, and the explanation given on pages 60 
and 61 applies to them also. 



90 DISEASES OF THE EYE. 

Retinoscopy. 
Another and very useful method for determining the re- 
fraction by the ophthalmoscope is termed the shadow test, or 
retinoscopy. The appearances upon which this method de- 
pends are due to the play of light reflected from the mirror 
on the fundus oculi. Either a concave or a plane ophthalmo- 
scopic mirror may be employed. I invariably use a plane 
mirror; but as I believe the majority of ophthalmologists still 
use the concave mirror in retinoscopy I shall describe the 




Fig. 41. 

theory and use of the method by its aid, and then that by aid 
of the plane mirror will be readily understood. 

If the rays from a light (Z, Fig. 41) be reflected from the 
concave mirror (iti) of an ophthalmoscope, they cross at a cer- 
tain point {A), and form there an inverted image of the flame, 
and then diverge again. If these diverging rays be made to 
pass through a convex lens (/>) placed at such a distance in 
front of a screen {E) that the rays meet at a focus on the lat- 
ter, a very small and brilliant upright image (0) of the flame 
is there formed, surrounded by a deep shadow. If the screen 



RETINOSCOPY. 91 

be moved slightly toward the lens (to //), so that the focus 
of the rays would lie behind it, or if it be removed slightly 
away from the lens (to J/), so that the focus come to lie in 
front of it, the brilliancy of the image on the screen and the 
intensity of the surrounding shadow are reduced ; because in 
each instance a circle of diffusion, and not an accurate image, 
is formed on the screen, and the further the focus of the pencil 
of rays is situated from the screen in either direction, the 
weaker does the image become and the more ill-defined the 
shadow,. 

If the mirror be rotated in various directions, the illumi- 
nated part ^ and the shadow are seen (care being taken to 
look at the screen directly, and not through the lens) to move 
on the screen in the opposite direction to the motion of the 
mirror. For example, if the position 7;/ (Fig, 41) be given 
to the mirror, the path of the rays reflected from it is shown 
by the dotted lines, and the image of is moved to 0\ 
This will also be the case if the screen be at H or at J/. 
These three positions of the screen may be supposed to repre- 
sent emmetropia (E), hypermetropia (//), and myopia (M). 
Figure 41 more particularly illustrates the motion of the light 
and shade in E and H only, while figure 42 demonstrates that 
in J/ 

In the eye, in like manner, the area of light and shade in 

"^ " The area of light," "the image," "the illuminated area, or part of the 
fundus," and " the illumination," are different terms for one and the same thing. 
The " shadow '" or " shade " refers merely to the margin of the illuminated area 
— L e. , where the illumination ceases and darkness begins ; it does not mean 
that the shadow of any object is thrown on the fundus oculi. When we speak of 
the motion of the shadow we mean that the margin of the illuminated area, or 
boundary-line between illuminated and non-illuminated area, moves along with 
the illuminated area in response to the motion of the mirror. It is easier to see 
how the illuminated area moves by watching the margin of the shadow (which 
comes across the pupil from behind the iris like a revolving shutter across a shop 
window), and hence it is that we have come to talk always of the motion of the 
shadow and not of the motion of the illuminated part. 



92 DISEASES OF THE EYE. 

the pupil moves against the motion of the mirror. Now we 
cannot, of course, see the real motion on the retina directly, 
but only through the dioptric media, and they will influence 
the apparent motion according to the condition of the re- 
fraction. 

In emmetropia and in hypermetropia the rays coming out 
of the observed eye are parallel and divergent respectively, 
and consequently, an upright image being formed by them in 
the observer's eye, the true motion given by the mirror is 
perceived. 

In myopia, at least in all cases of more than one D, the ob- 




FiG. 42. 

server does not see an upright image of the flame on the fun- 
dus of the observed eye, but a real inverted aerial image 
formed between his mirror and the observed eye. The reason 
of this is, that the rays coming out of the patient's eye are 
convergent and meet at a focus, which is the far point of the 
eye, and form there an inverted image of the object from 
which they come, and which, in this instance, is an upright 
image of the flame (the illuminated area). When, therefore, 
the upright image on the fundus moves against the mirror, the 



RETINOSCOPY. 93 

inverted image (which the observer sees) moves in the oppo- 
site direction — /. e., with the mirror. For example : If in 
figure 42 we suppose a to be the position of the image on 
the fundus of a myopic eye, and a'^ the position of its real 
inverted aerial image, a motion of the mirror to ;;/ (the rays 
reflected from vi' are omitted in order to avoid confusion in 
the diagram) throws the image of ^ to a\ as already ex- 
plained, but the inverted aerial image of a' is formed at a" — 
i. e., it seems to have moved with the mirror. 

In myopia alone, then, does the image move with the mir- 
ror ; while in emmetropia and hypermetropia it moves against 
the mirror. In low myopia (one D and less), as will just now 
be seen, the image also moves against the mirror. 




Fig. 43. 

From what has been said, it is evident that the higher the 
ametropia (the further from the screen, in figure 41, the focus 
of the rays) the larger and feebler the illumination becomes 
— /. e., the greater the circles of diffusion — and the more cres- 
centic the margin of the shadow, because it is the margin of 
a circle of diffusion. 

Again, the extent of the motion of the image and its rate 
are in inverse proportion to the degree of the ametropia. 
Thus, if figure 43 represents a myopic eye, whose far point is 
situated at a'^ , a motion of the mirror to in' may be supposed 
to throw^ the illuminated part to a' , and then a'^ will move to 



94 DISEASES OF THE EYE. 

^2'. But if the myopia be of less degree, so that the far point 
is at ^3, the same motion of the mirror will throw a^ io a^' , 
and the distance between these two latter points is evidently 
much greater than that between a"^ and a''-' . In a hyperme- 
tropic eye (Fig. 44) the image may be supposed to be formed 
at a, and a motion of the mirror to ?;/ will throw it to a' ; 
while in a higher degree of hypermetropia it would be formed 
at b, and the same motion of the mirror w^ould throw it to b' . 
The distance between b and b' is much greater than that be- 
tween a and a' . 

In practising retinoscopy with the concave mirror the sur- 
geon sits 1.20 m. in front of the patient. The eye to be ex- 




FiG. 44. 

amined is shaded from the direct rays of the lamp, if the latter 
be placed beside the patient ; but a better plan is to have the 
light above his head. The focus of the mirror should be 
22 cm., and any error of refraction of the surgeon is to be 
corrected. The light is then thrown into the eye at an angle 
of about 15^ with its axis of vision, so that if the pupil be not 
under the influence of atropin the macula lutea may be 
avoided. In children, and when the pupil is very small, it is 
advisable to dilate it with atropin, and then the region of the 
macula lutea may be utilized. When, now, the ophthalmo- 
scope is rotated in different directions, motions of the light and 
shade on the fundus oculi are seen in the pupillary area. The 



RETINOSCOPY. 95 

surgeon directs his attention to the edge of the shadow rather 
than to the illuminated part, for its motion is more easily ap- 
preciated. If the edge of the shadow move with the motion 
of the mirror, myopia is present ; if it move against \\\q mirror, 
emmetropia, hypermetropia, or myopia of one D or less is 
present. 

The reason why the motion is against the mirror in cases 
of M. I D and less is that the surgeon being seated only 
1.20 m. from the eye he is examining, if that eye have a 
myopia of one D, its far point is so close to his eye that he 
cannot clearly observe the image there formed ; but if the 
myopia be of even slighter degree, the image will be formed 
behind the surgeon's head, and he gets a shadow moving 
against the motion of his mirror, because the image he then 
sees is the upright one of the patient's fundus oculi and not 
the inverted aerial image. 

We proceed as follows : 

A trial spectacle frame is put on the patient's face. If the 
shadow move with the mirror we know at once the eye is 
myopic. To find the degree of myopia the surgeon puts a 
low concave glass, say — i D, into the frame ; and if the 
shadow still move with the mirror he puts in a higher number, 
say — 1.5 D, and so on until he comes to a glass which 
makes the image move against the mirror. If this be — 3 D, 
the myopia is three D. It might be supposed, as the shadow 
now moves against the mirror, that this glass over-corrects 
the myopia ; but this is not so, because, as already explained, 
when the myopia is very low the image is formed close to the 
surgeon's eye, or behind his head, and he consequently gets a 
shadow moving against the mirror, although low myopia, and 
not emmetropia, is present. Consequently — 0.5 D, or — i 
D, has to be added on to the lens, which gives the effect of 
no distinct shadow ; or rather, by the above plan, it is not de- 



96 DISEASES OF THE EYE. 

ducted from the lowest lens, which makes the shadow move 
against the mirror. 

If the shadow move against the mirror we have to determine 
whether the eye be emmetropic, h\'permetropic, or slightly 
myopic. Should the illumination be bright, and the shadow 
well defined, the eye is emmetropic, or not far removed from 
it ; and if the shadow be ill defined and crescentic we may 
feel sure the eye is highly hypermetropic. We first put on 
-|- I D, and if the motion be still against the mirror the case is 
one of hypermetropia, and higher numbers are at once pro- 
ceeded with until that one is reached which causes the shadow 
to move with the mirror. The measure of the hypermetropia 
is one D less than the glass so found, for it has evidently over- 
corrected the defect. 

If, however, on putting on -j- i D we find the shadow to 
move with the mirror, we change it for -|- o. 5 D ; and if still 
the motion be with the mirror, the eye is, beyond doubt, 
slightly myopic, — o. 5 D or so. But if with -{- i D the 
shadow move with the mirror, while with -f- 0.5 it continue to 
move against it, the eye is emmetropic. 

It may be found that in two opposite meridians there is a 
difference in the motion of the shadow, and this leads us to 
diagnose the presence of astigmatism. When the difference is 
one merely of rapidity of motion, or of intensity of illumina- 
tion and shadow, we know that we have to do with either 
simple or compound astigmatism. But if in the two meridians 
there be a difference in the direction of the motion, then it is a 
case of mixed astigmatism. The best method for ascertaining 
the degree of astigmatism and its correcting glass is to correct 
each of the principal meridians separately with spheric lenses. 
In compound astigmatism, the difference between the two 
lenses found indicates the degree of astigmatism and also the 
cylindric lens which, combined with the correcting spheric 



RETINOSCOPY. 97 

lens for the least ametropic meridian, is required to neutralize 
the defect. In mixed astigmatism, the addition of the two 
numbers gives the cylindric lens, while one or other of them, 
usually the -j- D, is used as the spheric lens. 

With i\\Q plane mirror the source of illumination of the ob- 
served eye is not a real inverted image of the light, as in the 
case of the concave mirror, but a virtual upright image behind 
the mirror ; and as this image moves in the opposite direction 
to the motion of the mirror, the motion of its illumination 
on the fundus of the patient's eye must be ivitJi the mirror 
in all cases, and not against it, as in using the concave mirror. 

With the plane mirror, therefore, the shadow is seen to move 
ivitli the motion of the mirror in H. and E. ; but in M. it seems 
to move agauist the motion of the mirror, for what we here 
see is an inverted image of the fundus situated at the far point 
of the eye. If the myopia be high, this inverted image will be 
close to the eye ; if low, it will be far away from it. In using 
the plane mirror, it is important to remember this point, be- 
cause, if the observer go nearer to a myopic eye than its far 
point he will not obtain a myopic motion, but one which is the 
same as that in E. or H. Consequently, in using the plane 
mirror, the rule is to go as far from the eye under examination 
as possible. If, at the beginning, the surgeon retire a little more 
than two meters from the eye, and there obtain a with-motion, 
he at once knows that the eye is not myopic o. 5 D ; or if he 
stand a little more than four meters away, and obtain the same 
motion, he knows there is not a myopia of even 0.25 D 
present. If the myopia be high, he will be able to begin close 
to the patient, but must gradually retire from the eye as he in- 
creases the number of the concave glass put up, for the far 
point is thereby moved further off, in order that he may not 
think he has corrected the myopia before he really has done 
so. Again, if at every distance the motion be with the mirror, 
the surgeon has to decide whether this indicate E. or H. He 



98 DISEASES OF THE EYE. 

does this by putting a low lens, say -)- 0.25, before the 
patient's eye, and if, then, standing at a distance of four meters, 
the motion be altered by this glass to one against the mirror, 
he knows that the eye has not a hypermetropia of 0.25 D, 
consequently that it is emmetropic. But if this lens does not 
at that distance cause a change in the motion of the shadow 
as originally obtained, the eye must be hypermetropic to at 
least the extent of 0.25 D ; and in order to ascertain how 
much more of H. than this may be present, it is now only 
necessary to go on increasing the strength of the lens in front 
of the patient's eye until one is reached which, at four meters 
from the eye, produces the myopic motion. The observer 
knows that he has now slightly over-corrected the hyper- 
metropia of the eye, and that the next lens lower is its measure. 

With some practice it is possible, unless the pupil be small, 
to obtain sufficient light from the fundus with the plane mirror 
at a distance of four meters. 

I find this method much more easily worked than that with 
the concave mirror. It has the advantage, too, of not requir- 
ing any wearisome addition to, or subtraction from, the data 
obtained. 

The pleasantest plane mirror is one of four cm. diameter, 
and of which the sight-hole is four mm. in diameter. 

Opacities in the refracting media can be best observed by ex- 
amination with strong convex lenses in the upright image. 
The further forward the opacity lies, the more hypermetropic, 
so to speak, it is, and the stronger the lens required. Very 
minute opacities of the cornea can be seen in this way with a 
-f 18 or -f- 20 D lens in the ophthalmoscope. 



THE NORMAL FUNDUS OCULI. 99 

FOCAL OR OBLIQUE ILLUMINATION 

is employed for the examination of the cornea, iris, and lens. 
With a high -[- lens, 16 to 18 D, the light of the gas-flame is 
concentrated on the part to be examined with an oblique, not 
a perpendicular, incidence of the concentrated rays. Small 
foreign bodies in the iris, cornea, or lens, or opacities in either 
of the latter can be thus detected. Extremely delicate opaci- 
ties in the cornea are not seen best with the strongest illumi- 
nation which can in this way be produced, but rather by the 
half-light which is obtainable at the edge of the cone of light 
passing from the lens. In examining the center of the crystal- 
line lens the incidence of the light must necessarily be more 
perpendicular. 



THE NORMAL FUNDUS OCULI AS SEEN 
WITH THE OPHTHALMOSCOPE. 

Reference has been made to the enlargement of the image 
of the fundus oculi seen with the ophthalmoscope. The cause 
of this enlargement is that the fundus is observed through a 
dioptric system at or close to the principal focus of which it is 
situated, and which consequently magnifies it to our view. 
The enlargement of the inverted image is not so great as that 
of the upright image, and it is smaller the shorter the focal 
length of the convex lens employed. The inverted image of a 
hypermetropic eye is larger than that of an emmetropic eye, 
and the latter larger than that of a myopic eye. It is possible 
to determine mathematically the degree of enlargement of the 
image ; but into this it is not necessary to enter. 

The Optic Papilla. — This is the first object to be sought 
for by the observer. It presents the appearance of a pale, 
pink disc, somewhat oval in shape, its long axis being vertical. 
Occasionally the long axis lies horizontally, and sometimes 



loo DISEASES OF THE EYE. 

the papilla is circular. The papilla is generally surrounded 
by a white ring, more or less complete, called the sclerotic 
ring, and often, outside this again, by a more or less complete 
black line, the choroid ring. The sclerotic ring fs due to the 
choroid margin not coming quite up* to the margin of the 
papilla, the foramen in the choroid for the passage of the optic 
nerve-fibers being somewhat larger than that in the sclerotic, 
and consequently a narrow edging of the white sclerotic is ex- 
posed. The choroid ring is the result of a hyper-develop- 
ment of pigment at the margin of the choroid foramen. The 
complexion of the optic papilla results from the pink hue de- 
rived from its fine capillary vessels, combined with the whiteness 
of the lamina cribrosa and the bluish shade of the nerve-fibers. 
It is frequently not equal all over, but is paler on the outer side, 
where the margin is more defined and where the nerve-fibers 
are often fewer on the inner side. The apparent color of the 
papilla depends also upon the complexion of the rest of the 
fundus. If the latter be highly pigmented the papilla appears 
pale in contrast ; while, if there be but little pigment in the 
choroid, the papilla may appear very pink. The complexion 
of every normal papilla is not identical, and care must be 
taken not to make the diagnosis *' hyperemia of the papilla," 
where merely a high physiologic complexion is present. The 
upper and lower margins of the papilla are often, especially in 
young people, a little indistinct, and show a delicate striation 
by the direct method of examination. This may be greatly 
exaggerated in hypermetropes, and has in them been some- 
times erroneously taken for optic neuritis. 

A physiologic excavation of the optic papilla is often met 
with. It is always on the temporal side of the papilla, and 
can be recognized from the parallax * which maybe produced, 
and from the paleness of this portion of the papilla. When 

* For explanation of the parallax see Chap. xii. 



THE NORMAL FUNDUS OCULI. loi 

the excavation is very deep, one may sometimes observe the 
lamina cribrosa in the form of gray spots (the nerve-fibers) 
surrounded by white lines (the fibrous tissue of the lamina). 

A physiologic excavation differs from a pathologic excava- 
tion by the fact that it does not reach the margin of the pa- 
pilla all round. It is caused by the crowding over of the 
nerve-fibers to the inner side of the papilla. Yet sometimes 
a healthy optic papilla will be met with in which the excava- 
tion apparently reaches the margin all round. Doubtless in 
such cases the thickness of the translucent nerve-fiber layer 
alone it is which is interposed between the sclerotic margin 
and the margin of the cup all round. 

The normal retina is so translucent that it cannot be seen, 
or at most a shimmering reflection or shot-silk appearance 
is obtained from it, particularly about the region of the yellow 
spot and along the vessels, but also toward the equator of the 
eye, and especially in dark eyes, and in young people. 

A peculiar but physiologic appearance known as " opaque 
nerve-fibers " is occasionally seen. It is produced by some 
of the nerve-fibers forming the internal layer of the retina re- 
gaining the medullary sheath on the distal aspect of the lamina 
cribrosa, or near the margin of the papilla, which they had 
lost in the optic nerve just before entering the lamina cribrosa, 
the rule being that the nerve-fibers lose their medullary sheath 
at the latter place definiteh', and enter the retina as axis- 
cylinders only, and hence are quite translucent. Instead of 
that, in these cases their fibers reflect the light strongly, giv- 
ing the effect of an intensely white spot, commencing at the 
papilla, extending more or less into the surrounding retina, 
and terminating in a brush-like extremity. This appearance 
is constant in the rabbit's eye. 

The macula lutea is generally seen as a bright oval ring 
with its long axis horizontal, this ring being probably a reflex 
from the surface of the retina. It is remarkable that this halo 



I02 DISEASES OF THE EYE. 

is not visible with the direct method of examination, a fact 
due probably to the illumination being much weaker than with 
the indirect method. The area inside the ring is of a deeper 
red than the rest of the fundus, and at its very center there is 
an intensely red point, the fovea centralis. This ring is not 
seen in old people. 

The general fundus oculi surrounding the optic papilla 
and macula lutea varies a good deal in appearance according to 
the amount of pigment contained in the choroid and in the 
pigment-epithelium layer of the retina, i. If there be an 
abundant supply of pigment in each of these positions, the 
choroid vessels are greatly hidden from view, and the effect 
is that of a very dark red fundus. 2. If there be but little 
pigment in the pigment-epithelium layer, the larger choroid 
vessels may be visible, and the fundus may appear to be 
divided up into dark islands surrounded by red lines. 3. If 
the individual be a blonde, there is little pigment either in the 
pigment-epithelium layer or in the choroid, and the fundus is 
seen of a very bright red color, the choroid vessels, down to 
their fine ramifications, being discernible. In albinos even the 
choroid capillaries may be seen. 

The Retinal Vessels. — The arteries are recognized as thin 
bright red lines running a rather straight course, in the center 
of each of which is a light-streak. As to the cause of this 
light-streak there is considerable divergence of opinion. Some 
attribute it to reflection from the coats of the vessel, or from 
the surface of the blood column ; while others believe that the 
light is reflected from the fundus through the vessel, which 
then acts as a very strong cylindric lens. This light-streak 
divides the vessel into two red lines. The veins are darker, 
wider, and more tortuous in their course than the arteries, and 
their coats not being so tense, the light-streak is very much 
fainter. 

On reaching the level of the nerve-fiber layer of the retina 



THE NORMAL FUNDUS OCULI. 



103 



the central artery and vein divide into a principal upper and 
lower branch. This first branching often takes place earlier in 
the vein than in the artery, and the former may even branch 
before appearing on the papilla, as in figure 45. The second 
branching may take place in the nerve itself; and when this 
occurs it will appear as though four arteries and four veins 




Fig. 45. — [Graefe and Saeviisch.') 
a.n.s. Art. nas. sup. a.n.i. Art. nas. inf. a.t.s., a.t.i. A. temp. sup. and inf. 
ii.n.s.^ v.n.i. Ven. nas. sup. and inf. v.t.s., v.t.i. Ven. temp. sup. and inf. 



a.m,e., v.m.e. Art. and ven. median. 



v.t.s. 
a.m. 



v.t.i. 

v.m. Art. and ven. macularis. 



sprang from the optic papilla ; but more usually this branching 
occurs on the papilla, as in figure 45. The vessels produced by 
this second branching pass respectively toward the median 
and temporal side of the retina, and are termed by Magnus the 
Art. and Ven. nasalis and temporalis sup. and inf (vide Fig. 
45). The temporal branches run in a radial direction toward 



I04 DISEASES OF THE EYE. 

the anterior part of the retina. A small horizontal branch, 
the Art. and Ven. mediana of Magnus, from the first principal 
branches is found passing toward the nasal side of the retina. 
The temporal branches do not run in a horizontal direction, 
but make a deto?ir round the macula lutea, sending fine branches 
toward the latter. Two or three minute vessels from principal 
branches run directly from the papilla toward the macula lutea, 
and around the macula lutea a circle of very fine capillary vessels 
is formed which cannot be distinguished with the ophthalmo- 
scope ; but no vessels run to or cross over the fovea centralis 
itself. The retinal arteries do not anastomose, nor do the 
larger retinal veins. The small retinal veins have some slight 
anastomoses near the ora serrata. Occasionally a vessel 
emerges near the margin of the disc, usually at the temporal 
side. It arises from the ciliary vessels, and is hence called a 
cilio-retinal vessel. 

No pulsation of the arteries is observable in the normal eye. 
In the larger veins near or on the optic papilla, or more usually 
just at their point of exit, a pulsation may sometimes be seen. 
This venous pulsation is due to the following sequence of 
events : Systole of the heart; diastole of, and high tension in, the 
retinal arteries ; consequent increased pressure in the vitreous 
humor ; communication of this to the outside of the walls of 
the retinal veins, impeding the flow of blood through them, 
especially in their larger trunks, which offer little resistance, or 
at their exit from the eye, where they offer the least resistance ; 
and in this way the veins are emptied — the blood gradually 
coming on from the capillaries overcomes the resistance, and 
the veins are for a moment refilled. The phenomenon can be 
most readily observed if the normal tension of the globe be 
slightly increased by pressure of a finger. 



CHAPTER IV. 

DISEASES OF THE CONJUNCTIVA. 

The conjunctiva consists of three portions : the palpebral^ 
lining the inside of the eyeUds ; the bulbar, covering the scle- 
rotic ; and a loose folded portion, uniting these two, which 
forms the fornix. When the conjunctiva reaches the mar- 
gin of the cornea it overlaps the latter a little, and this over- 
lapping portion is known as the limbus conjunctivae, or cornese. 

Hyperemia of the Conjunctiva. — In this condition the 
blood-vessels of the palpebral conjunctiva especially are en- 
gaged. Slight chemosis sometimes appears, small vesicles 
may form, and there may also be some swelling of the papillae 
and development of lymph-follicles. There is not any ab- 
normal discharge from the conjunctiva, and herein lies the 
chief point of difference between this affection and simple 
conjunctivitis. 

Causes. — Foreign bodies. Foul air, or air loaded with 
tobacco-smoke. Alcoholic excesses. Accommodative asthe- 
nopia. Stenosis lacrimalis, and other forms of lacrimal ob- 
struction. The use of unsuitable spectacles, or the use of the 
eyes for near work without spectacles when the condition of 
the accommodation — c. g., hypermetropia, presbyopia — re- 
quires them. 

Symptoms. — The eyes are irritable. There is lacrimation 
and photophobia, with hot, burning sensations, and sensations 
as of a foreign body in the eye, and the eyelids feel heavy. 
All these symptoms are aggravated in artificial light. 

Treatment. — In addition to the removal of the cause, iced 
9 105 



io6 DISEASES OF THE EYE. 

compresses are to be applied to the closed eyelids for twenty 
minutes several times a day, and the instillation of a drop of 
tincture of opium and distilled water in equal parts, morning 
and evening, will be found beneficial. It is also desirable to 
wash out the lacrimal passages with an Anel's syringe, even 
where no decided lacrimal obstruction is present. 

The eyes should be protected from the glare of light by 
dark glasses, and out-of-door exercise is to be recommended. 

Conjunctivitis in general. — In addition to hyperemia there 
is here abnormal secretion. There are several forms of con- 
junctivitis, the discharge from each being more or less conta- 
gious. The secretion from any given form will not, however, 
always reproduce that form, but may give rise to another of 
greater or less severity. Infection takes place by the direct 
application of the secretion, or also, it is very generally 
thought, through the air, in which float particles of the infect- 
ing substance. The latter mode is especially liable to exist, 
it is said, in an ill-ventilated room, where a number of people 
affected with conjunctival diseases are lodged with others who 
possess healthy eyes — e.g., in crowded charity-schools. The 
palpebral conjunctiva is often affected when the bulbar portion 
remains normal, and the conjunctiva of the lower lid is more 
frequently attacked than that of the upper lid. 

Catarrhal or Simple Acute Conjunctivitis. — In mild 
cases the affection is confined to the palpebral conjunctiva, 
often even to the conjunctiva of the lower lid ; but in the 
severer cases it extends to the bulbar conjunctiva. L}'mph- 
follicles and enlarged papillae are frequently present, but not 
necessarily so. There is a sticky, serous secretion which causes 
the eyelids to be fastened together on awaking in the morning, 
and sometimes produces ulceration of the intermarginal por- 
tion of the eyelids (intermarginal blepharitis). In some of 
the very mildest cases this ''stickiness" or " gumming " on 
awaking in the morning is a valuable diagnostic sign, for it is 



THE CONJUNCTIVA. 107 

in such cases difficult or impossible to recognize the very slight 
variation from the healthy appearance of the conjunctiva. 

In the severer cases, the papillae are markedly swollen, and 
may even conceal the Meibomian glands from view. Also 
one often sees small ecchymoses in the bulbar conjunctiva, 
especially in certain epidemics, but these have no serious 
import. 

Minute gray infiltrations sometimes form at the margin of 
the cornea. When there are many of them they may become 
confluent and form a small gray crescent, which ulcerates, 
and thus a crescentic marginal ulcer is formed, and very occa- 
sionally such an ulcer is followed by iritis. 

The catarrh may become chronic, and then the papillae are 
more developed, while the blepharitis is liable to extend over 
to the cutis, causing eversion of the lower punctum lacrimale 
with resulting stillicidium, and this, in its turn, aggravates 
the conjunctival affection. 

Tlie symptoms are those of a severe case of hyperemia 
— sensations of sand in the eye ; hot, burning sensations ; 
weight of the eyelid — with the addition of the annoyance con- 
sequent on the secretion, which, by coming across the cornea, 
may cause momentary clouding of sight. Photophobia is not 
generally severe unless there be some corneal complication. 

Causes. — Drafts of cold air. Contagion. Foul atmo- 
sphere. As an epidemic. Foreign bodies. i\s a sequel of 
or attendant on scarlatina, measles, and small-pox. 

Diagnosis. — The presence of the gummy secretion distin- 
guishes this affection from mere hyperemia of the conjunc- 
tiva. A common mistake amongst those not familiar with 
eye diseases is to regard a case of iritis as one of simple acute 
conjunctivitis, the redness of the white of the eye in the 
former affection being taken for conjunctival hyperemia, etc. ; 
and, moreover, a slight secondary conjunctivitis does undoubt- 
edly attend many cases of iritis. 



io8 DISEASES OF THE EYE. 

The circumcorneal subconjunctival vessels, which are the 
episcleral branches of the anterior ciliary vessels, are those 
which become engorged in iritis, and their engorgement gives 
rise to a pink or pale violet zone around the cornea, of which 
the separate vessels cannot be distinctly seen. The conjunc- 
tival vessels may be distinguished from the subconjunctival or 
ciliary vessels by the possibility of moving the former, along 
with the membrane in which they are, by manipulations 
which can be made wath the lower lid of the patient, while 
these manipulations do not affect the ciliary vessels. The 
separate conjunctival vessels, too, can be easily distinguished, 
and they are of a bright red color. The appearance of the 
iris itself, however, is that upon which the diagnosis finally 
depends. (See Iritis, Chap, x.) 

The progjiosis is good if there be no reason to suspect that 
the mild form is but the commencement of a more severe in- 
flammation. The infiltrations, and even the ulcers, which 
sometimes form at the margin of the cornea, are not often of 
serious import, and usually heal according as the treatment 
restores the conjunctiva to health. 

Treatment. — Cold or iced compresses, with the use of a four 
per cent, solution of boracic acid as a lotion, should be used 
frequently at the first onset, and in mild cases will alone 
bring about a cure. But the habit which some patients so 
readily acquire of bathing the eyes frequently w^ith cold water 
should not be permitted, for it is deleterious to the conjunc- 
tival affection. When in a day or two the irritation and swell 
ing have somewhat subsided, or from the very commence- 
ment, if there be not much irritation, a solution of nitrate of 
silver, or from five to ten grains to oj, should be applied by 
the surgeon to the palpebral conjunctiva with a camcl's-hair 
pencil, the lid being w^ell everted, and this then should be 
thoroughly neutralized with salt water, the whole being finally 
washed off with plain water. The application is to be repeated 



THE C0N7UNCTIVA. 109 

in twent}'-four hours, by which time the sHght loss of epi- 
thelium, the result of the superficial slough, will have been 
repaired. Immediately after such an application cold spong- 
ing or iced compresses are useful and grateful to the patient. 
The greatest care is required in the use of nitrate of silver in 
conjunctival affections for any prolonged period lest it cause 
that brownish staining of the membrane called argyrosis 
{apyupo^, silver)] thorough neutralization and washing as above 
recommended being the best safeguards. I am opposed to 
the use even of weak solutions of nitrate of silver as eye-drops 
to be used at home by the patient, for staining is very apt to 
be caused in this way. 

Should the surgeon be unable to see the patient daily, the 
following simple eye-drops are capable of effecting a rapid 
cure in most cases : 

^ . Acid boracici, gr. v 

Zinci sulph., gr- ij 

Tinct. opii, '^] 

Aq. destill., ad 5J. 

One drop in the eye morning and evening, or only once a day in mild cases. 

Solutions of alum (gr. iv to oj of water) and of tannic acid 
(gr. V to viij to 5j of water) are often prescribed, but are not so 
effectual as the foregoing. 

A weak boracic acid ointment, to be applied along the 
margins of the lids at bedtime, is to be ordered. It prevents 
the gumminess in the* morning, which is not only unpleasant 
to the patient, but is also injurious by fastening the eyelids 
together, and thus preventing free drainage of the secretion 
during the night. 

Follicular Conjunctivitis. — This is catarrhal conjunctivitis, 
to which is added the presence, in the conjunctiva, of small, 
round, pinkish bodies the size of a pin's head, which disappear 
completely as the process passes off, leaving the mucous mem- 
brane as healthv as thev found it. These little bodies are situ- 



no DISEASES OF THE EYE. 

ated chiefly in the lower fornix of the conjunctiva, and may be 
discovered by eversion of the lower lid, when they will be seen 
arranged in rows parallel to the margin of the hd. Whether 
they are easily discovered or not depends on their size and 
number and on the amount of coexisting hyperemia or chemo- 
sis of the conjunctiva. The structure of these bodies shows 
them to be lymph-follicles. 

Follicular conjunctivitis is a very tedious affection, lasting 
often for months. According to Saemisch, it is more apt to 
give rise to marginal ulceration of the cornea than the simple 
catarrhal form ; but I have not myself observed this. I agree 
with those w^ho hold that the disease has nothing to do with 
granular ophthalmia, although some authors regard it as an 
early stage of the latter. 

The symptoms are much the same as those of catarrhal 
conjunctivitis. Frequently there is little or no injection of 
the bulbar conjunctiva, and the chief symptom is asthenopia — 
an inability to continue near work for any length of time — 
and much distress in artificial light. Boys and girls from five 
to fifteen years of age are those most liable to this affection. 

Causes. — These are also much the same as in simple catar- 
rhal conjunctivitis. The long-continued use either of atropin 
or of eserin is liable to bring on the disease. 

Treatment. — The remedy I have found most useful in this 
troublesome affection is an ointment of sulphate of copper of 
from gr. ss to gr. ij, in 5j of vaselin. The weaker ointments 
should be used at first, and later on the stronger ones, if it be 
found that the eye can bear them. The size of half a pea 
of the ointment is inserted into the conjunctival sac with a 
camel's-hair pencil once a day. Eye-drops of equal parts of 
tincture of opium and distilled water are of use in some cases ; 
and the eye-douche should be recommended. Abundance of 
fresh air, w^ith change from a damp climate or neighborhood 
to a dry one, is of importance. If the use of a solution of 



THE CONJUNCTIVA. iii 

atropin has induced the disease it should be discontinued ; 
and if a mydriatic be still required, a solution of extract of 
belladonna (gr. viij ad 5J) may be employed in its stead. 

Spring catarrh is the eye complication which accompanies 
that troublesome affection known as " Hay Fever." It is 
not, strictly speaking, a catarrhal affection, for it is usually 
unattended by secretion, and the prefix " Spring " is mislead- 
ing, as it is seen also in summer and autumn. The hay harvest 
is the most common period for it, owing probably to certain 
minute particles which then float in the air. 

The bulbar conjunctiva is chiefly affected. It becomes in- 
jected, slightly edematous, and close around the cornea it is 
somewhat elevated, with grayish swellings. The margin of 
the cornea itself is apt to become invaded with minute infil- 
trations. 

Some individuals are liable to be attacked at each hay har- 
vest. The chief symptoms are photophobia and lacrimation. 
The affection is unattended with danger to the eye. 

The microscope shows (Uhthoff) that the conjunctival 
swelling is due to hypertrophy of the epithelial layer of the 
conjunctiva in this situation, combined with sub-epithelial infil- 
tration with a substance which is, or is similar to, coagulated 
albumen. The deeper layers of the conjunctiva remain toler- 
ably normal. 

Trcaimcnt. — This is usually an excessively troublesome af- 
fection to cure. Dark glasses for protection from the light, 
weak astringent coUyria (sulphate of zinc, acetate of lead), 
with cold sponging, or the douche, are useful ; or, iodoform 
ointment (i in i 5), a little put into the eye once a day. Pagen- 
stecher highly recommends massage twice daily in conjunction 
with strong precipitate ointment. 

Trachoma {jpayy^^ rough), Granular Conjunctivitis, or 
Granular Ophthalmia (also called Egyptian Ophthalmia and 
Military Ophthalmia). — In this disease, in addition to the usual 



112 DISEASES OF THE EYE. 

appearances of simple conjunctivitis^ there are developed 
grayish or pinkish-gray bodies about the size of the head of a 
pin, situated in and close to the fornix conjunctivae, chiefly of 
the upper lid, but also disseminated over other parts of the 
membrane, except that they do not form on the bulbar con- 
junctiva. These bodies are the trachoma bodies or granula- 
tions, and in the acute form of the disease they somewhat 
resemble the folhcles of follicular conjunctivitis, but are paler, 
not so apt to occur in rows, and are more isolated. Micro- 
scopically, the trachoma bodies have no capsule, as have the 
follicles, but seem to grow from or in the stroma of the con- 
junctiva. In the acute form, the trachoma bodies consist of 
lymph-cells alone, but in the chronic form this is true of them 
only toward their surface, while at their bases they are formed 
chiefly of connective tissue. They are to be regarded as new- 
growths in the conjunctiva. 

According to some observers (Reid, ** Muttermilch " *) who 
have examined various forms of conjunctivitis microscopically, 
the differences between them are only in the degree of the 
hypertrophy of the sub-epithelial adenoid tissue, which occurs 
in all. All stages of transition exist, they say, from small 
sub-epithelial collections of round cells to characteristic 
trachoma, which, according to them, is not a distinct disease, 
but can be developed from other forms of conjunctivitis under 
certain conditions of health and surroundings. 

The disease comes under our notice in two forms — the 
acute and the chronic. The latter may result from the 
former, but more commonly we find it as the primary condi- 
tion, without any appreciable acute stage having gone before. 

Causes. — Both forms are contagious, and probably the 
infection occurs only by transference of the secretion from one 
eye to the other by means of fingers, towels, handkerchiefs. 



Annales d' Oculistique, 1893, p. 4I. 



THE C0^7U^XTIVA. 113 

etc. Hence the more slovenh' in their personal habits, and 
the more crowded in their dwelhngs, families, schools, or 
barracks nations ma}* be, the more likeh' is this disease to 
spread from one indixidual to another when it once gains a 
foothold. A great deal, however, remains to be learned as 
to the manner in which contagion takes place. For instance, 
inoculation with discharo-e from an acute case mav o-ive rise 
onh" to catarrhal or purulent conjuncti\"itis, which may recover 
completeh'. Again, the infectiousness of chronic cases cannot 
be ver\' CTeat, for nurses and doctors rarelv, if ever, o-et in- 
fected by their patients. Neither do we see trachoma patients 
infecting other patients in the hospitals in this countr}-, where 
the disease is so prevalent. Were the infectiousness of the 
disease ver\- great, even the precautions taken in a well-ordered 
hospital against contagion would hardly be sufficient to pre- 
vent such an occurrence occasional!}'. 

It has been stated that the acute form is often epidemic in 
places where the hygienic conditions are bad ; but in this 
countr}- I ha\-e never seen it as an epidemic, and sporadicalh' 
not often, although the chronic form is extremely common in 
Ireland. 

Amongst the better classes, both here and elsewhere, the 
disease is ven- uncommon. High, dr}', mountainous coun- 
tries are almost free from this disease, so that, probabh', the 
atmospheric conditions pla}- some part in the etiolog}'. 

Some hold that the affection is dependent on constitutional 
disease, such as scrofula, tuberculosis. S}-philis, etc., but I 
cannot indorse this view. No doubt man}- of these patients 
are anemic and out of health, but this is due to the moping 
habits they contract and the little open-air exercise the}^ take 
in consequence of their semi-blindness. 

Acute Trachoma, or Acute Granular Ophthalmia. — As 
alread}' stated, this is an affection rarel}- seen in this countn-. 
An attack commences with swelling of the upper lid, great 



114 DISEASES OF THE EYE. 

injection of the whole of the bulbar and palpebral conjunctiva, 
and swelling of the papillae, with development of the charac- 
teristic trachoma bodies. There may be but little discharge, 
but there is generally much lacrimation, with photophobia, 
and great pain in the brow and eye. Superficial marginal 
ulcers of the cornea may form. 

The inflammation and papillary swelling increase for a week 
or so to such a degree that the granulations are hidden from 
view ; and then, taking on a blennorrheic form, the process 
gradually subsides, until, in the course of two or three weeks 
longer, the blennorrhea disappears, having brought about 
absorption of the granulations, and ultimately the mucous 
membrane is left in a healthy state. 

If, however, in the blennorrheic stage the inflammation be 
excessive, the eye may run all the dangers of an attack of 
acute purulent conjunctivitis ; or if, on the other hand, the 
inflammation be very slight, it may not be sufficient to effect 
absorption of the granulations, and the process may run into 
the chronic form. 

Egyptian ophthalmia, which is an acute form of trachoma, 
seems to be a combination of trachomatous disease with puru- 
lent ophthalmia, as the gonococcus can always be found in 
the discharge.* 

Treatment. — It is desirable to abstain from active measures 
in the commencement of the affection, owing to the tendency 
to natural cure which is often present, and especially astrin- 
gents and caustics should be avoided. At the utmost an an- 
tiseptic lotion of boracic or salicylic acid, and cold applications 
for relief of the pain and heat are admissible. Dark protec- 
tion-glasses are agreeable, and, wearing them, the patient 
should be encouraged to take open-air exercise. But if it be 
evident that the inflammatory reaction is not active enough, 

* Demetriades, Annal cV Oail. , 1894, p. 19. 



THE CONJUNCTIVA. 115 

poultices or warm fomentations should be employed to pro- 
mote it. Once the blennorrheic stage has been reached great 
care is required to control it, and if it threaten to exceed safe 
bounds it must be restrained by means of suitable applica- 
tions, such as acetate of lead, nitrate of silver, or sulphate of 
copper in solutions of medium strength ; or it ma}^ be neces- 
sary to use them in strong solutions, or to employ the solid 
mitigated nitrate of silver. 

Chronic Trachoma, or Chronic Granular Ophthalmia. 
— The first onset of this disease is often without inflammation, 
and is then unattended by any distressing symptoms, except 
that the eye may be more easily irritated by exposure to cold 
winds, foreign bodies, etc., or more easily wearied by reading 
and other near work. If such a case come under our notice, 
the conjunctiva will be found free from infection or swelling ; 
but grayish-white, semi-transparent trachoma bodies, of the 
size of a rape-seed and less, will be seen disseminated over 
the conjunctival surface and protruding from it. Gradually 
these trachoma bodies or granulations give rise to a more or 
less active vascular reaction, attended with swelling of the pa- 
pillae and purulent discharge — in short, blennorrhea. The 
patients then begin to be more inconvenienced, owing to the 
discharge which obscures their vision, and to sensations of 
weight in the lids, and of foreign bodies in the eye ; and this, 
consequently, is generally the earliest stage at which we see 
the disease. The enlarged papillae sometimes grow to a great 
size, completely hiding the granulations. In this stage the 
granulations may become absorbed, and the disease undergo 
cure ; but more commonly it makes further progress. Fresh 
granulations appear, while the old ones increase in size until 
they often become confluent, leaving only here and there an 
island of vascular mucous membrane. Sometimes the trachoma 
bodies are very small, and present the appearance of minute 
white dots, and in this form they are not always easily found. 



ii6 



DISEASES OF THE EYE. 



These chronic granulations consist of lymph-cells toward 
their surface, but toward their bases are formed chiefly of 
connective tissue. Gradually the cellular elements are trans- 
formed into connective tissue, and in this way cicatricial de- 




FlG. 46. — [Saemisch.) 
a. Muscle, b b. Tarsus having undergone fatty degeneration, c. Atrophied 
Meibomian gland, d d. Hypertrophied papilla, e. Cicatricial tissue in the 
conjunctiva, f. Tarsus. 

generation of the conjunctiva is brought about at each spot 
where a granulation was seated. 

As the disease advances, the submucous tissue becomes 
implicated in the connective-tissue alterations, while the tarsus 



THE CONJUNCTIVA. 



117 



undergoes fatty degeneration and becomes hypertrophied. 
The granulations disappear, having reduced the conjunctiva to 
a cicatrix. Contraction of the diseased conjunctiva on the 
inner surface of the Hd causes entropion and distortion of the 
bulbs of the eyelashes, followed by irregular growth of the 
latter, with resulting trichiasis and distichiasis. These changes 
are represented in figure 46. 

The great danger of granular ophthalmia lies in the compli- 
cations which may attend it or which follow in its wake ; the 
former consist in pannus and ulcers of the cornea and severe 




Fig. 47. 

purulent conjunctivitis, while the latter are the distortions of 
the lids and eyelashes just referred to. 

Pannus (Lat., a cloth rag) presents the appearance (Fig. 47) 
of a superficial vascularization of the cornea, with more or less 
diffuse opacity, and often small infiltrations. It invariably 
commences in the upper portion of the cornea, extending 
generally over the upper half, and frequently remains confined 
to this region. But in many cases, at a later stage, it extends 
to the whole surface of the cornea ; and this latter occurrence 
often takes place almost suddenly ; and the vascularization and 
opacity sometimes become so intense as to present quite a 



Ii8 DISEASES OF THE EYE. 

fleshy appearance, completely hiding the corresponding part 
of the iris from view. Histologically, pannus consists of a new 
growth, which is extremely rich in cells, and which closely 
resembles the conjunctiva when occupied with confluent 
granulations. It is situated between the corneal epithelium 
and Bowman's layer, and is permeated by vessels derived from 
the conjunctival vessels. After a length of time Bowman's 
layer becomes destroyed in places, and then the cellular infil- 
tration gains access to the true cornea, and gives rise to per- 
manent changes in its transparency and curvature. In some 
bad cases of old-standing pannus the latter undergoes a con- 
nective-tissue change. It then becomes smooth on the surface, 
and the vessels almost disappear, so that the cornea is covered 
with a thin layer of connective tissue, which obstructs the 
passage of light and is not capable of cure. 

Another result of pannus, sometimes, is a bulging or 
staphylomatous condition of the cornea, the tissues of which 
have become so altered that they give way before the normal 
intraocular tension. 

A pannus in which as yet there is no connective-tissue 
alteration, and where there is no staphylomatous bulging, is 
capable of undergoing cure without leaving any opacity be- 
hind except that which may be due to ulcers that have been 
present. 

Pannus is usually a painless affection, but is sometimes ac- 
companied by photophobia and ciliary neuralgia. It may come 
on at any stage of the disease, and causes defective vision in 
proportion to the degree and extent of the opacity. Severe 
pannus is liable to induce iritis. 

The connection between pannus and the condition of the lids 
is not altogether evident. It was for long held that the corneal 
affection is due to mechanical irritation, caused by the rough 
palpebral conjunctiva ; but this view is obviously incorrect, for 
severe pannus is often seen with a comparatively smooth con- 



THE C0^7UXCTIVA. 119 

junctiva, while \\ith a truh' rough conjunctiva the cornea is 
frequent!}- perfectly clear. There can now be little doubt that 
pannus is analogous to the granular disease in the conjunctiva. 
It is, in fact, the same disease, modified by reason of the differ- 
ent tissue in which it is situated, this different tissue being itself 
a modification of the conjunctiva ; and it Avould seem probable 
that the cornea becomes diseased by direct inoculation from 
the conjunctiva of the upper lid. Yet it is remarkable that the 
bulbar conjunctiva h'ing between the upper margin of the 
cornea and the fornix of the upper lid ne\-er becomes ap- 
parently diseased. 

Prognosis. — At an}- period prior to cicatrization of the con- 
junctiva an attack of purulent blennorrhea is liable to come 
on. If not too severe this may result in a cure b}- absorption 
of the trachoma bodies, and should not be checked. If, how- 
ever, the attack be x^ry severe the e}-e runs dangers similar to 
those of an ordinar}- attack of purulent conjuncti\-itis. These 
dangers are less the more complete and the more intense the 
pannus. 

On the whole, if the disease come under treatment at an 
earl}- period, it ma}- be hoped that vision will be retained in a 
majority of cases, although a radical cure ma}- be difficult or 
impossible. These cases require to be under constant or inter- 
mitting treatment for long periods, often for }'ears, and are ex- 
tremely liable to relapses. 

Trcatiiicut. — The aim of this is to bring about absorption of 
the trachoma bodies with the greatest possible despatch, in 
order to prevent the destruction of the mucous membrane to 
which the}- tend. Xo caustic appHcation should be made with 
the object of directh- destroying the trachoma bodies, fortius 
can onl}- be done at the expense of the mucous membrane 
around them. As alread}- said, in cases of chronic granular 
ophthalmia in which a blennorrheic attack comes on, when this 
passes off again the trachoma bodies are found to have become 



I20 DISEASES OF THE EYE. 

much fewer, or to have quite disappeared. Following the hint 
nature thus gives us, we should endeavor, by our treatment, to 
produce a certain papillary reaction. For chronic cases, with 
Httle swelling of the papillae (blennorrhea), and with little or 
no cicatrization, the best application is the solid sulphate of 
copper lightly applied to the conj unctiva, especially at its fornix ; 
but when there is considerable papillary sweUing I prefer a ten- 
grain solution of nitrate of silver, properly neutralized after its 
application with a solution of salt, or a light application of 
mitigated lapis, similarly neutralized. An interval of twenty- 
four hours at least should be allowed to elapse between each 
application, whether of sulphate of copper or nitrate of silver, 
and cold sponging for fifteen minutes should be employed im- 
mediately after the application. A change of treatment will 
be occasionally required even if the remedy first used answer 
well in the beginning, and one or other of the following can 
be adopted : Pure carbolic acid liquefied has been used * 
with good result, but I have no experience of it. It is applied 
with a camel's-hair pencil, and the excess washed off with plain 
water. Liq. plumb, acetatis dil, never to be used except with 
everted lids, and washed off w^ith plain w'ater by the surgeon ; 
and not even in this way if there be ulcers of the cornea, as 
the corneal tissue forming the floor of the ulcer is liable to 
become impregnated with a white deposit, probably the 
albuminate of lead, which is by no means easy to remove by 
operation subsequently. Tannin ointment: Tannin gr. j, to 
vaselin 5j, the size of half a pea, to be put into the eye once 
a day. Sulphate of copper ointment : Same strength as the 
last, and to be used in the same way. Solution of alum : Gr. 
X to oj of distilled water ; one drop in the eye once a da\-. 
Where an active pannus is present, a drop of solution of atro- 



* Recently again by E. Treacher Collins, /^oy. Loud. Ophthal. Hasp. Rep., 
Vol. xi, p. 340. 



THE COXJU^XTIVA. 121 

pin should be instilled into the eye once a day as a precaution 
against iritis. 

Some surgeons employ scarifications of the conjunctiva when 
it is much swollen and the papillae too exuberant ; but I have 
never adopted them, fearing the resulting cicatrices. 

Scraping of the conjunctiva with a sharp spoon, Avith sub- 
sequent rubbing in of i : 500 corrosive sublimate solution, has 
recently been recommended. 

Again, it has been proposed to excise, or abscise, the 
trachoma bodies ; and this may perhaps be allowable if they 
are isolated and protrude much over the surface of the con- 
junctiva. 

Squeezing out the granulations between the thumb-nails 
used to be practised by the late Sir William Wilde, of Dublin, 




Fig. 48. 

and has recently again come into use. But the proceeding 
of " expression " is nowadays performed by means of an instru- 
ment instead of by the finger-nails. The best instrument for 
the purpose is Knapp's roller forceps * (Fig. 48). Two small 
grooved cylinders are inserted in the forked ends of a strong 
forceps, so that they roll over the surfaces of a body which 
may be grasped between them when the instrument is drawn 
upon. The retro-tarsal fold of the lower or upper lid is 
grasped as far back as possible between the cylinders, com- 
pressed and drawn upon, and in this way the trachomatous 
tissue is squeezed out without laceration of the conjunctiva. 
The instrument has to be reinserted and a neighboring part 

* Trails. Auier. Ophfhal. Soc. for 1891, and At'chives of Ophthal. (English 
edition), 1893, p. ill. 



122 DISEASES OF THE EYE. 

of the conjunctiva treated in the same way, and so on until 
the whole conjunctiva of each affected eyelid has been oper- 
ated on. The four eyehds may be manipulated at one sitting, 
and the evacuation should be so complete that a repetition of 
the proceeding will not be required. Particular care should 
be taken to reach the part of the conjunctiva which is hidden 
under the commissures. If the tarsal portions are affected, 
one cylinder may be applied to the outer surface of the lid, 
and the instrument so drawn across the lid that the other 
cylinder presses the trachoma bodies out of the tarsal conjunc- 
tiva. As the operation is painful, and cocain not of much 
avail in it, it is, as a rule, desirable that the patient should be 
under the influence of an anesthetic. Some cases are imme- 
diately and permanently cured by this operation ; while others, 
although greatly benefited, will still require a further routine 
treatment with local remedies. Expression is indicated only 
where trachomatous substance can be pressed out. My ex- 
perience with this method leads me to regard it as a useful 
one for the acceleration of the cure of some cases of granular 
ophthalmia before the cicatricial stage has come on. 

Excision of the fornix conjunctivae has been proposed by 
Schneller,* and largely practised by him and other surgeons. 
It is claimed for this method that it shortens the treatment 
of all forms of the disease ; that, after it, existing corneal 
processes undergo rapid cure; that the granular disease in the 
palpebral conjunctiva, although not directly included in the 
operation, disappears quickly ; that recurrences of the disease 
are rarer than by other plans of treatment ; and that the 
resulting linear cicatrix has no serious consequence, and is as 
nothing when compared with the extensive cicatricial degener- 
ation of the whole mucous membrane wliich the operation is 



* Fon Graefe' s Archiv, Vol. xxx, No. 4, p. 131 ; and Vol. xxxiii, No. 3, 
p. 113. 



THE CONJUNCTIVA. 123 

calculated to prevent. Supplemental treatment with the 
customary local applications is employed until the cure is 
obtained. I find that this is a useful procedure in some cases. 
Infusion of jequirity (^Abnis precatorms, paternoster bean), 
long used in the Brazils, has been introduced to the notice of 
European surgeons by de Wecker. The infusion is made by 
macerating 154 grains of the decorticized jequirity seeds in 16 
ounces of cold water (a three per cent, infusion) for twenty-four 
hours. Twice a day for three days the lids are everted, and the 
infusion thoroughly rubbed into the conjunctiva with a sponge 
or bit of lint. The result is a severe conjunctivitis of a some- 
what croupous tendency (even the cornea being often hidden by 
the false membrane), accompanied by great swelling of the eye- 
lids, much pain, and considerable constitutional disturbance, 
rapid pulse, and temperature of 100°, or more. In the course 
of eight or ten days the inflammation subsides, and the cornea 
in many cases will then be found to be free from pannus, or 
almost so, while complete cure of the granular ophthalmia 
itself is rarer. Iced compresses to the eyelids should be used 
during the inflammation. A fresh infusion, not more than 
seven days old, must be emplo}'ed in order to secure the best 
reaction. The majority of surgeons, amongst them myself, 
find the remedy harmless, if not always successful ; but a good 
many cases are on record where violent diphtheritic conjunc- 
tivitis, followed by blennorrhea of the conjunctiva, and by more 
or less extensive ulceration of the cornea, and even complete 
loss of the eye, were produced. I have, two or three times, 
seen a small superficial ulcer form on the lower third of the 
cornea without further injury. De Wecker regards the pres- 
ence of a purulent discharge from the conjunctiva as a contra- 
indication for the remedy, which he finds is then liable to in- 
crease the intensity of the blennorrhea in a dangerous degree. 
Cases where there is little or no papillary swelling, but nearly 
dry trachoma bodies with pannus, are the most suitable for its 



124 DISEASES OF THE EYE. 

use, and I cannot recommend it too highly in these cases. It 
is marvelous to see the rapid and beautiful cures of the severest 
pannus by this remedy in properly selected cases. But the 
presence of well-marked pannus of the cornea without ulcer- 
ation is, I think, the only thing that can render the employ- 
ment of jequirity justifiable, and in addition to this the con- 
junctiva should be free from blennorrhea. 

The occurrence of acute dacryocystitis sometimes forms an 
unpleasant complication of the jequirity treatment, even in 
cases in which the sac was previously quite normal ; but I have 
never myself seen it to occur. 

After the subsidence of the jequirity inflammation some of 
the local remedies above referred to should be regularly 
applied for the purpose of completing the cure of the con- 
junctival condition. 

Besides local remedies, it is of great importance that the 
hygienic surroundings of patients suffering from granular 
ophthalmia be seen to, and that they be obliged to spend a 
considerable time daily in the open air. 

If the upper li-d be tightly pressed on the globe, as it 
sometimes is, the physiologic pressure varying in different 
individuals, an impediment is offered to the cure by any 
method, and pannus is" promoted. It is then necessary to 
relieve the pressure by a canthoplastic operation. (See Chap. 

Peritomy. — This procedure is adopted for the cure of pannus 
by destruction of the vessels which supply it, and is as 
follows : About five mm. from the margin of the cornea an 
incision is made in the conjunctiva with scissors, and carried 
at this distance all the way round the cornea. This ring of 
conjunctival tissue is then separated up from the sclerotic, 
and cut off at the corneal margin, and the underlying con- 
nective tissue is dissected off the corresponding portion of the 
sclerotic, which is thus laid quite bare. The proceeding is 



THE C0^7U^XTIVA. 125 

not always satisfacton-, and of late years I have practised it 
but little. 

Lymphoma of the Conjunctiva, — Under this heading 
cases have been recently described "^ which present the appear- 
ances, at first sight, of acute granular ophthalmia ; but the 
" eranulations," which are enormous in size, attack both lids, 
and are associated with enlarged lymphomatous masses in the 
neck, which do not lead to ulceration or scarring. The con- 
junctival affection runs a rapid and favorable course, without 
any cicatricial contraction. 

Acute Blennorrhea of the Conjunctiva, or Purulent 
Ophthalmia. — We most commonly find this very dangerous 
affection either as gonorrheal ophthalmia or as blennorrhea 
neonatorum. 

Etiology. — In the former, the etiologic moment is the intro- 
duction of some of the specific discharge from the urethra or 
vagina into the conjunctival sac ; while in the latter, the infec- 
tion is believed to take place either during or just after the 
passage of the head through the vagina, b\- an abnormal 
secretion from the latter finding its way into the infant's e}-es. 
A few instances have been observed of infants born with the 
disease. Inoculation may also occur a few days afterbirth by 
pus conveyed by the fingers of the mother or nurse, or by 
towels, etc., used for washing the child's face. It is never 
due to exposure to strong light or to cold, as is popularly 
supposed. 

The more severe cases of blennorrhea neonatorum are 
caused bv a vao"inal discharo-e, which is alwavs gronorrheal. 
Neisser, who first observed the presence of a peculiar micro- 
coccus in the gonorrheal discharge, also found the gonococcus 
in the pus from the conjuncti\-a in cases of gonorrheal 
ophthalmia, and the same micrococcus has been found in the 

* Goldzieher, Centralblatt. f. Aiigenheilk., 1893, p. 112. 



126 DISEASES OF THE EYE. 

conjunctival discharge in cases of blennorrhea neonatorum. 
But the slight cases of the latter affection, which amount to 
little more than a catarrh of the conjunctiva, may be caused 
by a vaginal discharge which is not of the specific gonorrheal 
nature. 

If the infection take place during or immediately after 
birth, the disease appears from the second to the fifth day, 
according to the virulence of the secretion. If the inflam- 
mation come on later than the fifth day, it may be concluded 
that the infection was produced by the vaginal discharge 
being introduced into the eye by the fingers of the mother 
or nurse, etc. Acute conjunctival blennorrhea also comes 
about w^ithout any assignable cause ; but in all such cases it 
may be regarded as certain that the introduction of some 
infective pus into the eye has taken place, although without 
the knowledge of the patient. 

Symptoms and Progress. — In mild cases the bulbar conjunc- 
tiva may be but little or not at all affected ; the palpebral 
conjunctiva alone becoming velvety and discharging a small 
amount of pus, while there may be no swelling or edema of 
the eyelids. Such mild cases are not uncommon in ophthalmia 
neonatorum. In severe cases of blennorrhea of the conjunc- 
tiva there is, soon after the onset, serous infiltration of the 
palpebral mucous membrane, which consequently becomes 
tense and shiny ; serous chemosis (yabto^ to gape open '^') of 
the bulbar conjunctiva ; serous discharge ; dusky redness and 
swelling of the eyelids, which makes it difficult to evert them ; 
pain in the eyelids, often of a shooting kind ; burning 
sensations in the eye, and photophobia. This first stage lasts 
from forty-eight hours to four or five days. 

Then begins the second stage, in which, owing to swelling of 



■^ Probably from the appearance produced when the conjunctiva in this condi- 
tion is much elevated round the margin of the cornea. 



THE CONJUNCTIVA. 127 

the papillae, the palpebral conjunctiva becomes less shiny and 
more velvety ; while the discharge alters from serous to the 
characteristic purulent form, the chemosis, however, remaining 
unaltered, or becoming more firm and fleshy. The swelling 
of the lids continues, the upper lid often becoming pendulous 
and hanging down over the under lid ; while, at the same time, 
it becomes less tense and more easily everted. Gradually 
the chemosis and swelling of the conjunctiva and eyeHds sub- 
side, and the discharge lessens, the mucous membrane finally 
being left in a normal state, unless in a small percentage of 
cases in which chronic blennorrhea remains. A moderately 
severe attack of conjunctival blennorrhea lasts from four to 
six weeks. 

Complications with corneal affections form the great source 
of danger from this affection. They are found chiefly in four 
different forms : i. Small epithelial losses of substance on any 
part of the cornea. If these occur at the height of the inflam- 
mation they are apt to go on to form deep perforating ulcers. 
2. The whole cornea becomes opaque (diffusely infiltrated), and 
toward its center some grayish spots form, which are interstitial 
abscesses or purulent infiltrations. 3. The infiltration may 
form at the margin of the cornea, and extend a considerable 
distance around its circumference, giving rise to a marginal 
ring ulcer, and, later on, to sloughing of the whole cornea. 
4. A clean-cut ulcer may form at the margin of the cornea 
without any purulent infiltration of the corneal tissue, and 
may also extend a long way round the cornea. Such ulcers 
are particularly apt to occur where there is much chemosis 
which overlaps the margin of the cornea ; and, being hidden 
in this way, these ulcers are easily overlooked. The chemosis 
should be pushed aside with a probe, and these peculiar ulcers 
looked for. They are very liable to perforate. 

All the foregoing forms of corneal complication occur both 



128 DISEASES OF THE EYE. 

in Ophthalmia neonatorum and in gonorrheal ophthalmia. 
They may appear at any period of the affection, but the earher 
they occur the more likely are they to result seriously. 

The danger of these ulcers consists in the perforation of 
the cornea they are apt to produce, of which more later on. 

The severer the case, especially the more the bulbar con- 
junctiva is involved in the process, the more likely is it that 
corneal complications will arise. For the corneal process is 
to be regarded as the result of infection by the conjunctival 
secretion, and this infection is all the more apt to occur where 
the nutrition of the cornea is impeded by a dense chemotic 
swelling of the bulbar conjunctiva. Severe chemosis is less 
common in the blennorrhea of the new-born than in gonor- 
rheal ophthalmia, and this is the chief reason for the fact that 
the latter is the more dangerous affection of the two. 

Treatme7it. — -The prophylaxis of purulent ophthalmia must 
here first engage our attention. 

It is a most important matter, and should form part of the 
routine of lying-in practice. Careful disinfection of the vagina 
before and during birth, and the most minute care in cleansing 
the face and eyes of the infant immediately after birth with a 
non-irritating disinfectant — c.g.^ a solution of corrosive subli- 
mate I : 5000 — are to be recommended. The method of the 
late Dr. Crede has found very general acceptance, and is a 
good one. It is as follows : When, after division of the um- 
bilical cord, the child is in the bath, the eyes are carefully 
washed with water from a separate vessel, the lids being scru- 
pulously freed by means of absorbent wool of all blood, slime, 
or smeary substance, and then, before the child is dressed, a 
few drops of a two per cent, solution of nitrate of silver are 
instilled into the eye. Many obstetricians employ this method 
now in a routine manner in their lying-in hospitals for all the 
infants, whether or not it be suspected that there is danger of 



THE CO^■TU^XTIVA. 129 

infection, and by its aid Crede reduced the percentage of his 
cases of ophthahnia neonatorum from eight or nine per cent, 
to 0.5 per cent. 

The action of the nitrate of sih^er solution depends, prob- 
ably, upon the destruction of the superficial layers of the con- 
junctival epithelium, and of the gonococci contained in them. 
Other antiseptic applications which have been tried do not act 
as well, for they do not destroy the superficial epithelium. 

In all cases of gonorrhea it is the dut}* of the surgeon to 
explain to his patients what is the danger of their carr}-ing any 
of the urethral discharcre to their eves, and to charcre them to 
exercise punctilious cleanliness as regards their hands and 
finger-nails, and care in the use of towels, handkerchiefs, etc. 

In respect of local treatnicnt when the disease has once 
broken out : In the commencement of the affection the onh* 
local applications admissible are antiseptic lotions, — boric acid ; 
corrosive sublimate — and iced compresses, or Leiter's tubes. 
With the former the conjunctival sac should be freely washed 
or irrigated, not syringed out. In syringing out the conjunc- 
tival sac a morsel of the corneal epithelium may be removed, 
and through this the cornea become infected, and therefore 
this method is objectionable. The iced compresses, or Leiter's 
tubes, should be kept to the eye for an hour at a time, with a 
pause of an hour, and so on, or even continuoush'. In this 
and in the next stage the chemosis should be freely and 
daily incised with scissors. If the swelling of the lids be 
great, the external canthus should be divided with a scalpel 
from without, leaving the conjunctiva uninjured, in order to 
reduce the tension of the eyelids on the globe, and. by bleed- 
ing from the small vessels, to deplete the conjunctiva. De- 
pletion alone can be obtained by leeching at the external can- 
thus, and in many cases is of great benefit at the ver}- com- 
mencement. If, in adults, the chemosis, palpebral swelling, 
and rapidity of the onset indicate that the inflammation is se- 



I30 DISEASES OF THE EYE. 

vere, it is well, in my opinion, to place the patient quickly 
under the influence of mercury by means of inunctions or 
small doses of calomel, as by so doing the chemosis is often 
rapidly brought down and one source of danger to the cornea 
removed. 

In the second stage — /. c, when the conjunctiva has become 
velvety and the discharge purulent — caustic applications are 
the most trustworthy, and in this respect iodoform and other 
lauded means cannot compete with them. The application 
employed may be a solution of nitrate of silver of i 5 to 20 
grains in oj of water, which should be applied by the surgeon 
to the conjunctiva of the everted lids, and then neutralized 
with a solution of common salt, as described when discussing 
the treatment of simple catarrhal conjunctivitis ; or the solid 
mitigated nitrate of silver (one part nitrate of silver, two parts 
nitrate of potash) may be used, the first application being mild, 
in order to test its effect, while careful neutralization with 
salt water and subsequent washing with fresh water are most 
important. 

The immediate effect of a caustic application to the conjunc- 
tiva is the production of a more or less deep slough, under 
which a serous infiltration takes place. This latter increases, 
and finally throws off the slough, and then the epithelium 
begins to be re-formed. From the time the slough separates, 
until the epithelium has been regenerated, a diminution in the 
secretion may be noted ; but the discharge again increases as 
soon as the regenerative period is ended, and this now is the 
moment for a new application of the caustic. From one 
caustic application of ordinary severity until the end of the 
regenerative period about twenty-four hours usually elapse. 
Immediately after a caustic application iced compresses should 
be used for thirty minutes or longer. Between the caustic 
applications the pus should be frequently washed away from 
the eyelids and from between the eyelids with a four per cent. 



THE CON'TUXCTIVA. 131 

solution of boric acid or with a i : 5000 solution of corrosive 
sublimate, and boric acid ointment should be smeared along 
the palpebral margins to prevent them from adhering, and 
thus retaining the pus. 

No corneal complication contraindicates the active treat- 
ment of the conjunctiva by the method just described. Iodo- 
form, finely pulverized, has been much praised as a local 
application in the second stage of acute blennorrhea of the 
conjuncti\"a. It is to be dusted freely on the conjunctiva once 
or twice a day. For my part, I should trust to it in mild cases 
only. 

When but one e}-e is affected it is important to protect its 
fellow from infection by means of a hermetic bandage. This 
may be made by applying to the eye a piece of lint covered 
with boracic acid ointment, and over this a pad of borated 
cotton wool. Across this, from forehead to cheek and from 
nose to temporal region, are laid strips of lint soaked in 
collodion in layers over each other ; or a piece of tissue gutta- 
percha ma}- take the place of the lint and collodion, its mar- 
gins being fastened to the skin b\- collodion. The shields 
invented by ]\Iaurel and by Buller are serviceable for this 
purpose. 

Treatment of Corneal Complications. — Many surgeons, I un- 
derstand, use solution of the sulphate of eserin (gr. ij ad aq. 
5J) dropped into the e}-e as soon as any corneal complication 
arises, and as long as it continues, on the ground that this 
drug is believed to have the effect of reducing the intraocular 
tension — a circumstance to be desired in these instances — and 
also to act as an antiseptic. Its power to reduce the normal 
intraocular tension is not great, and its antiseptic action, if it 
exist, must be ver}- insignificant, while, in my opinion, it has 
a decided tendenc}- to promote iritis in these cases, where the 
iris is so liable to become inflamed secondarily to the corneal 
process. I therefore do not recommend its use in these cases. 



132 DISEASES OF THE EYE. 

I employ atropin here with the object of diminishing the ten- 
dency to iritis. Only if a marginal ulcer should perforate, 
with prolapse or danger of prolapse, into the opening, is eserin 
indicated, and then simply for the purpose of drawing the iris 
out of or away from the perforation by the contraction of its 
sphincter. 

On the first appearance of an ulcer or infiltration of the 
cornea, besides the use of atropin nothing can be done further 
than the steady continuance of the conjunctival treatment, no 
remission or relaxation of which is indicated or, indeed, ad- 
missible. Greater care is now required in everting the lids, 
lest pressure on the globe might cause rupture of the ulcer ; 
and it should be remembered that when a case of acute blen- 
norrhea first presents itself, the surgeon, not knowing the 
condition of the cornea, must use the utmost caution in making 
his examination, and yet must never fail to get a view of the 
cornea for the purposes both of prognosis and of treatment. 
At each visit the cornea must be examined, and it may be 
found that as the conjunctival process subsides, any existing 
corneal affection also progresses toward cure, infiltrations be- 
coming absorbed and ulcers filled up. But, even though the 
conjunctiva be improving, and still more so if it be not, the 
corneal process may progress, the infiltration becoming an 
ulcer, and the ulcer becoming gradually deeper, until, finally, 
it perforates. 

Should a corneal ulcer become deep and seem to threaten 
to perforate, paracentesis of the floor of the ulcer must be re- 
sorted to without delay. By thus forestalling nature, a short 
linear opening is substituted for the circular loss of substance, 
which would have resulted in the ordinary course of events. 
Through this small linear opening no prolapse of the iris, or 
else a relatively small one, takes place ; and consequently the 
ultimate state of the eye is usually a better one than it would 
otherwise be. The reduction of the intraocular tension after 



THE COXJUXCTIVA. 133 

the paracentesis promotes healing of the ulcer. It is often 
desirable to evacuate the aqueous humor b}- opening the little 
incision in the floor of the ulcer with a blunt probe on each 
of the two days after the operation. 

If an ulcer perforate spontaneoush*, the aqueous humor is 
evacuated, and, unless the ulcer be opposite the pupil, and at 
the same time small m size, the iris must come to be applied 
to the loss of substance. Should the latter be very small, the 
iris will simply be stretched over it and pass but little into its 
lumen, and when healing takes place will be caught in the 
cicatrix, which is but slightly or not all raised over the sur- 
face of the cornea, and the resulting condition is called ante- 
rior synechia. 

If the perforation be larger, a true prolapse of a portion of 
the iris into the lumen of the ulcer takes place. This prolapse 
may either act as a plug, filling up the loss of substance and 
keeping back the contents of the globe, but not protruding 
over the level of the cornea, or it may bulge out over the 
corneal surface as a black globular swelling, and may then 
play the part of a distensor of the opening, causing fresh in- 
filtration of its margins. In either case cicatrization will 
eventually occur ; and if the scar be fairh^ flat, it is called an 
adherent leukoma, but if it be bulged out the term partial 
staph}-loma of the cornea is used. 

If the perforation be ver\- large, invohing the greater part 
of the cornea, with prolapse of the whole iris and closure of 
the pupil by exudation, the result is a total staphyloma of 
the cornea. The lens ma}* lie in this staph}-loma, or it may 
retain its normal position, but become shrunken. 

The question of the treatment of a recent prolapse of the 
iris in cases of blennorrheic conjunctivitis is an important one. 
It has been, and is still largely, the practice to abscise small 
iris-protrusions down to a level with the cornea, or if large to 
cut a small bit off their summits, with the object of obtaining 



134 DISEASES OF THE EYE. 

flat cicatrices. Horner * pointed out that in cases of blen- 
norrhea this proceeding opens a way for purulent infection of 
the deep parts of the eye, and that serious consequences are 
not rare. He confined interference with the iris in these eyes 
to. incision of the prolapse, when it seems to be acting as a 
distensor of the opening, causing fresh infiltration of the 
cornea. Under other circumstances he restricted his treat- 
ment of the prolapse to the instillation of eserin, which has a 
marked effect in diminishing the size of the protrusion. 

It may occur that on the surgeon's visit to a case of blen- 
norrhea of the conjunctiva he will find the margins of the eye- 
Hds gummed together by sero-purulent secretion, while the 
eyelids are bulged out by the pent-up fluid behind them. 
The attempt to open the eye should then be very cautiously 
made, lest some of the retained pus spurt into the surgeon's 
eye. The surgeon should also be most careful to thoroughly 
wash and disinfect his hands and nails at the conclusion of his 
visit. 

In cases of blennorrhea neonatorum, when the ulcer has 
been small, on perforation taking place, the lens, or rather its 
anterior capsule, comes to be applied to the posterior aspect 
of the cornea. The pupillary area is soon filled with fibrinous 
secretion. The opening in the cornea ultimately becoming 
closed, the iris and lens are pushed back into their places by 
the aqueous humor which has again collected. Adherent to 
the anterior capsule on the spot which lay against the cornea 
is a morsel of fibrin, which gradually becomes absorbed by 
the aqueous humor. In the meantime changes have been 
produced by this exudation on the corresponding intracap- 
sular cells, which result in a small, permanent, central opacity 
at that place, where there is also a slight elevation of pyra- 
midal shape over the level of the capsular surface. This con- 

^Gerhardt's " Ilaridbuch der Kindeikranklieiten," Bd. v, Abth. ii, p. 268. 



THE C0^7U^XTIVA. 135 

dition is called central capsular cataract, or p\-ramidal cataract, 
and rarel}- results from corneal perforation in adults. 

In cases of blennorrhea neonatorum an inflammatory swell- 
ing of the joints, so-called gonorrheal arthritis, is very occa- 
sionally seen. Deutschmann"^ found the gonococcus in the 
fluid removed from the joints in two such cases, while other 
observers found in their cases only the usual pyogenic cocci. 

Croupous Conjunctivitis. — This is a disease of early 
childhood, and is not common. The palpebral conjunctiva is 
a good deal swollen, and is covered with a false membrane 
that may be peeled off, leaving a mucous surface underneath 
which bleeds little or not at all. The disease is not a severe 
one. and does not cause secondary corneal aflections, unless 
when the bulbar conjunctiva, as it very rarely does, partici- 
pates in the attack. It must not be mistaken for diphtheritic 
conjunctivitis, from which it is readily distinguished by the 
ease with which, in it, the false membrane can be removed, 
and by the vascular condition of the underlying mucous 
membrane. 

This is usuall}- regarded as nothing more than a severe form 
of catarrhal conjuncti\'itis, in which the secretion happens to 
be rich in fibrin, and hence possessed of a marked tendency 
to coagulate on the surface of the conjunctiva. But the pres- 
ence of virulent diphtheria bacilli has been demonstrated in a 
case of apparent croupous conjuncti\"itis which ran a favor- 
able course.! 

Some cases of membranous conjunctivitis become chronic, 
lasting for months, t 

Causes. — Contagion ; epidemic. 

Treatment. — Iced compresses or Leiter's tubes to the eye- 

"^ Arch, fi'cr OphtJial.^ xxxvi, i, p. 109. 

tUhthofF, Berlin Klin. Wochenschr., 1893, No. 1 1. 

% Trans. Ophthal. Soc. Un. Kingd., Vol. xiii, p. 26. 



136 - DISEASES OF THE EYE. 

lids during the croupous stage, with antiseptic cleansing of the 
conjunctival sac (sol. hydrarg. perchlor., i : 5000 ; or sol. acid, 
borac, four per cent.). No caustic should be used in this stage, 
as it is apt to produce corneal changes. Sulphate of quinin 
sprinkled on the conjunctiva is praised by some surgeons as a 
useful application at this period. When the false membrane 
ceases to be formed a slight blennorrhea comes on, and this 
is to be treated with nitrate of silver applications in the usual 
way. 

Diphtheritic Conjunctivitis. — ^There is no more serious 
ocular disease than this, for it may destroy the eye in twenty- 
four hours, while in severe cases treatment is almost power- 
less. Fortunately, it is almost unknown in these countries, 
while in Berlin it used to be so frequent that von Graefe set 
apart two wards for it in his hospital, which were under my 
care as his assistant. It is now a much less common disease 
there, owing probably to the improved hygiene of the city. 

The subjective symptoms of its initial stage are similar, 
although severer, especially in the matter of pain, to those of 
blennorrheic conjunctivitis. The objective symptoms differ 
from those of blennorrhea, in that the lids are excessively 
stiff, owing to plastic infiltration of the sub-epithelial and 
deeper layers of the conjunctiva, while the surface of the 
mucous membrane is smooth, and of a grayish or pale buff 
color. If an attempt be made to peel off some of the super- 
ficial exudation, the surface underneath will be found of the 
same gray color, not red and vascular as in croupous conjunc- 
tivitis. This stage of infiltration lasts from six to ten days, 
and constitutes the period of greatest peril to the eye ; for 
while it lasts the nutrition of the cornea must suffer, and 
sloughing of that organ is extremely apt to take place. To- 
ward the close of the first stage the fibrinous infiltration is 
eliminated from the eyelids, and the conjunctiva gradually as- 
sumes a red and succulent appearance, and at the same time a 



THE C0^7UXCTIVA. 137 

purulent discharge is established. This constitutes the second 
or blennorrheic stage. A third stage is formed b}- cicatricial 
alterations in the mucous membrane, which often lead to 
symblepharon, or to xerophthalmos ; so that, even if the eye 
escape corneal dangers in the first and second stages, others 
almost as serious may await it in the final stage. 

Corneal complications are most likely to occur in the first 
stage, and are then also most likely to prove destructive to the 
eye. The earlier they appear, the more dangerous are they. 
If the blennorrheic stage come on before corneal complica- 
tions appear, or even before an ulcer contracted in the first 
stage has advanced far. they are more easily managed. 

Causes. — It is difficult to assign a cause for this disease, 
which chiefl}- attacks children. It is frequenth' epidemic, is 
extremely infectious, and although similar in its nature, is 
rarely, if ever, found in connection with an attack of diphthe- 
ritis of the fauces. 

Treatment. — In the first stage, frequent warm fomentations, 
with antiseptic cleansing, are the only local measures admis- 
sible. Xo caustic or astringent application should be used. 
Internall}-. the patient should be treated with iron and qui- 
nin, and generous diet. In the second or blennorrheic stage, 
careful caustic applications are to be used. Corneal ulcers 
must be dealt with whenever they arise in the same way as 
though the case were one of blennorrheic conjunctivitis. 
When the purulent discharge ceases, solutions of soda, milk, 
or ghxerin ma\- be prescribed as lotions for the conjunctiva, 
to arrest, if possible, the xerophthalmos. 

Conjunctival Complication of Small-pox. — Of this I 
have, fortunately, too little experience to enable me to speak 
authoritatively. The following embodies the views of the late 
Professor Horner,* who studied the subject during an epi- 

"^Lcc. cif., p. 297. 



138 DISEASES OF THE EYE. 

demic in 187 1. A good deal of uncertainty prevailed previ- 
ously, for the initial stages of the eye affection were not care- 
fully observed by physicians owing to the swelling of the eye- 
lids, while the ophthalmologist saw only the results of the 
process in the period of convalescence. 

Small-pox pustules on the cornea are, Horner believed, ex- 
tremely rare ; indeed, he saw but one such case. The most 
frequent and most serious mode of attack consists in a grayish- 
yellow infiltration in the conjunctiva close to the lower margin 
of the cornea, not extending to the fornix conjunctivae, nor 
far along the inner or outer margin of the cornea. It occurs 
in the eruptive stage, and is to be regarded clinically as a va- 
riola pustule. This infiltration or pustule gives rise to a cor- 
neal affection, as does a solitary marginal phlyctenula, either 
in the form of a marginal ulcer or as a deep purulent infiltra- 
tion, ulcerating, perforating, leading to staphyloma, purulent 
irido-choroiditis and panophthalmitis — results which are often 
first observed long after the primary conjunctival affection has 
disappeared. 

Horner believed that the germ of the conjunctival infiltra- 
tion makes its way between the eyelids, and that the con- 
stancy of the position of the infiltration below the cornea is 
accounted for by this theory ; that part of the conjunctiva, 
with closed eyelids and eyeball consequently rotated upward, 
being the most exposed to particles entering. 

Treatment. — On this ground he recommended the prophy- 
lactic use of boracic acid ointment on lint applied over the 
eyelids. If a conjunctival pustule has already formed with- 
out any or only commencing corneal affection, he would de- 
stroy the pustule with fresh chlorin water, or with mitigated 
lapis carefully neutralized. Corneal complications are treated 
as in blennorrhea of the conjunctiva or diphtheritis. 

The frequency with which the eyes become affected varies 
in different epidemics. 



THE CONJUNCTIVA. 139 

As true post-variolous eye-affections, Horner recognized 
diffuse keratitis, iritis, and irido-cyclitis, with opacities in the 
vitreous humor, and glaucoma ; in the hemorrhagic form of 
the disease, hemorrhages in the conjunctiva and retina ; and 
where pyemic poisoning comes on, septic affections of the 
choroid and of the retina take place. 

Amyloid Degeneration. — This rare disease attacks chiefly 
the palpebral conjunctiva, but is also seen in the bulbar por- 
tion. It causes great tumefaction of the affected lid, without 
any inflammatory symptoms. The eyelid can be but partially 
elevated, and is often so stiff and hard that it can be everted 
only with difflculty. The conjunctiva has the appearance of 
white wax. The disease ultimately extends to the tarsus, but 
is a strictly localized process, and not associated with amyloid 
disease in any other part of the system. It sometimes seems 
to be developed from granular ophthalmia, but occurs also as 
a primary disease. The positive diagnosis can be made by 
submitting a small portion of the diseased conjunctiva to the 
iodin test. 

Hyalin degeneration of the conjunctiva has also been ob- 
served. It cannot clinically be distinguished from amyloid 
degeneration, and is really an early state of the latter condi- 
tion. 

Treatment consists in the removal of the diseased parts, by 
the knife and scraping, so far as may be possible. 

Tubercular Disease of the Conjunctiva. — This is an 
extremely rare disease. It commences in the palpebral con- 
junctiva of the upper lid usually, very rarely in the bulbar con- 
junctiva, as small, round, yellowish-gray nodules, which soon 
ulcerate. The margins of these ulcers are well defined, and 
their floors of a yellowish lardaceous appearance, or covered 
with grayish-red granulations. The surrounding conjunctiva 
is swollen, and if the palpebral conjunctiva be much involved 
the lid becomes enlarged in every dimension, and the ulcera- 



I40 DISEASES OF THE EYE. 

tive process may soon destroy part of the lid. It may also 
». extend to the bulbar conjunctiva, and the cornea may become 
covered with pannus. The pre-auricular and submaxillary 
glands usually become enlarged. The positive diagnosis of 
the nature of the disease should be made by an examination 
of portions of the floor of the ulcer for the characteristic 
tubercle bacillus, which will distinguish this from secondary 
syphilitic ulceration of the conjunctiva, between which and 
the tubercular ulceration there is sometimes a resemblance. 
Tubercular conjunctival disease is usually unattended by pain, 
or there is only a slight burning sensation ; but again, when 
the ulceration is extensive, severe pain may set in. 

This is a very chronic disease, its progress sometimes ex- 
tending over many years, and it is rarely met with except in 
youth. Some of those whose eyes are attacked are already 
the subjects of tuberculosis in other organs, but very many 
of them are perfectly healthy in that respect. In fact, we 
have reason to believe (Valude, Leber) that tuberculosis of 
the conjunctiva is much more often a primary disease, the 
result of an ectogenic infection, even in cases where already 
tuberculosis exists elsewhere, than of infection occurring 
through the blood. Tubercle bacilli, introduced into the 
normal conjunctival sac, have, it is true, been found to be 
harmless, for the intact epithelium offers an insuperable 
obstacle to their entrance into the tissue. But a superficial 
loss of substance of the conjunctiva is sufficient to allow of 
its inoculation with the bacilli, and then the disease becomes 
established. The frequent lodgment of foreign bodies under 
the upper hd explains why this is the most common place for 
the disease to begin in. But although conjunctival tubercular 
disease is not often secondary to tubercular disease in other 
parts of the system, yet it is itself liable to be the starting- 
point of general tuberculosis. 

Treatment. — The fact last mentioned makes it most import- 



THE CONJUNCTIVA. 141 

ant in cases of primary tubercular disease of the conjunctiva 
to thoroughly eradicate the diseased focus so as to avert an 
infection of other organs, and this can often be effected. 
If the ulcers be not already too extensive, they must be 
scraped, and the actual cautery freely applied to them ; and 
where the disease has already spread to the cornea, sclerotic, 
iris, or choroid, enucleation of the eyeball is imperatively 
called for. 

Lupus of the conjunctiva usually occurs as an extension 
of the disease from the surrounding skin, or rarely from the 
lacrimal sac, as in a case of Dr. Werner's, where the disease 
extended from the mucous membrane of the nose through 
both lacrimal sacs to the inferior palpebral conjunctiva. It is 
seen as a patch or patches of ulceration, covered with small 
dark-red protuberances or granulations, chiefly on the palpebral 
conjunctiva, which bleed easily on being touched. 

Like lupus of the skin, these ulcerations undergo spon- 
taneous healing and cicatrization in one place (unlike tuber- 
cular ulceration in that respect) while they are still creeping 
over the surface in another direction. But we now know that 
lupus, wherever it occurs, is really a tubercular disease, and 
that the two forms differ only in their clinical aspect. 

TJie treatment is scraping with a sharp spoon, and the ap- 
plication of the actual cauter}'. 

Pemphigus of the Conjunctiva. — This is another rare 
disease. It has been seen in connection with pemphigus 
vulgaris of other parts of the bod}', but it also occurs as an 
independent disease. It is attended b}' attacks of much pain, 
photophobia, and lacrimation ; and the conjunctiva, at each 
place where subconjunctival exudation of serum has been 
situated, undergoes degeneration and cicatricial contraction. 
Such attacks succeed each other at shorter or longer intervals, 
for weeks, months, or years, until, finally, the entire conjunc- 
tiva of each eye may have become destroyed, and the eyelids 



142 DISEASES OF THE EYE. 

are adherent to the eyeball. The cornea gradually becomes 
completely opaque, or, having ulcerated, becomes staphylo- 
matous. In the course of the disease the eyelashes are apt 
to become turned in on the eyeball, or even entropion may 
form ; and these conditions aggravate the suffering of the 
patient. 

The foregoing is a description of a severe case. In less 
severe cases the conjunctiva may not be completely destroyed, 
and the cornea may not be affected. 

The formation of a true bulla hardly ever occurs, for the 
conjunctival epithelium is so delicate that it cannot be dis- 
turbed in this way by the serous exudation beneath it, but 
rather breaks down at once. Consequently the conjunctival 
surface is found in these cases to be covered by what looks 
like a membranous deposit, upon removal of which a raw sur- 
face is exposed ; and these appearances have led to the mis- 
taken diagnoses of croupous and of diphtheritic conjunctivitis. 

Treatment is helpless in respect of arresting the progress of 
the disease, or of restoring sight when lost in consequence of 
it. The most one can do is to relieve the distressing symp- 
toms by emollients to the conjunctiva, and by the use of 
closely fitting goggles, to protect from wind, dust, and sun. 
Internally, arsenic is indicated. 

Xerosis {^-qpoq, dry), or xerophthalmos, is a dry, lusterless 
condition of the conjunctiva, associated in the severer forms 
with shrinking of the membrane. There are two forms of the 
affection — the parenchymatous and the epithelial. 

In parenchymatous xerophthalmos there is a more or less 
extensive cicatricial degeneration of the conjunctiva, dependent 
upon changes in its deeper layers, while its surface and that of 
the cornea become dry, and the latter becomes opaque, and 
the eye consequently sightless. The conjunctiva shrinks so 
completely in many of these cases that both lids are found 
adherent in their whole extent to the eyeball, which is exposed 



THE CONJUNCTIVA. 



143 



merely at the palpebral fissure, where the opaque and luster- 
less cornea is to be seen. From what remains of the con- 
junctiva, scales, composed of dry epithelium, fat, etc., peel 
away. The motions of the eyeball are restricted in proportion 
to the extent of the conjunctival degeneration. There is no 
cure for this condition. 

Figure 49 represents a case of xerophthalmos, the result of 
pemphigus, which was under my care in the National Eye and 
Ear Infirmary. Here the ^ 

eyelids were not wholly ad- 
herent to the eyeball, and the 
cornea remained clear. 

Tlie causes of parenchyma- 
tous xerosis of the conjunc- 
tiva are granular ophthalmia, 
diphtheritic ophthalmia, pem- 
phigus, and the condition is 
said to be very occasionally 
seen as a primary disease, 
described as essential shrink- 
ing of the conjunctiva. Many 
observers altogether deny the 
existence of the primary 
affection, and maintain that 
the cases described as of that 
nature are merely the result 
of pemphigus, and I am inclined to agree with this view. 

Treatment. — As cure is impossible in this form of xeroph- 
thalmos, the only indication is to afford relief, so far as it can 
be done, from the distressing sensations of dryness of the eyes 
which are complained of The best applications are milk, 
glycerin, olive oil, and weak alkaline solutions, and the eyes 
should be protected from all irritating influences by protection 
goggles. 




Fig. 49. 



144 DISEASES OF THE EYE. 

Epithelial xerosis of the conjunctiva is confined to the epi- 
thelium of that part of the conjunctiva which covers the ex- 
posed portion of the sclerotic in the palpebral opening. It 
there becomes dry and dull and covered with small white 
spots ; while the whole bulbar conjunctiva is loose, and easilv 
thrown into folds by motions of the eyeball, and there maybe 
a good deal of secretion. This form of xerophthalmos often 
occurs in epidemics, but also sporadically, accompanied, oddly 
enough, by night-blindness (the light-sense unimpaired) and 
contraction of the field of vision. The combined condition 
has been noticed chiefly in persons of debilitated constitution, 
who have been exposed to strong glares of light, and is said 
to have appeared in epidemics, under these conditions, in for- 
eign prisons and barracks. 

Treatment by rest, protection from glare of light, nutritious 
diet, and tonics, invariably restores the eyes to their normal 
functions. 

Again, epithelial xerosis occurs in very young children in 
connection with a destructive ulceration of the cornea. (See 
Infantile Ulceration of the Cornea with Xerosis of the Con- 
junctiva, Chap, viii.) 

Pterygium (Ttripu^, a wing). — This is a vascularized thick- 
ening of the conjunctiva, triangular in shape, situated most 
usually to the inside of the cornea, sometimes to its outer 
side, and rarely either above or below it. The apex of the 
triangle, the head of the pterygium, is on the cornea ; and its 
base, the body, at the semi-lunar fold. The neck of the pter- 
ygium is that part of it at the margin of the cornea. There 
is frequently, but not always, a tendency of the growth to ad- 
vance into the cornea, of which it seldom reaches the center, 
and still more rarely extends quite across it. 

In its early growth the pterygium is rather thick and suc- 
culent-looking, and very vascular. But finally it ceases to 
grow, and then becomes thin and pale, and this is its retro- 



THE CONJUNCTIVA. I45 

gressive stage ; yet it never entirely disappears. Sight is not 
affected unless the pter}^gium extends over the pupillary re- 
gion of the cornea. A limitation of the motion of the eye to 
the other side, and consequent diplopia, is sometimes caused 
by a pterygium ; but for the most part the disfigurement alone 
it is which brings these cases to the surgeon. 

Cause. — The starting-point of a pterygium is often an ulcer 
at the maro-in of the cornea, which in healing- catches a morsel 
of the limbus conjunctivae and draws it toward the cicatrix, 
throwing the mucous membrane into a triangular fold. The 
ulcer then forms anew in the cornea immediately inside the 
cicatrix, and, in healing, the point of conjunctiva is drawn into 
it again, and is carried a little farther into the cornea, and so 
on. The hollow lying between a pinguecula (see below) and 
the margin of the cornea is apt to lodge small foreign bodies, 
which cause shallow marginal ulcers, and these, in healing, 
draw the pinguecula over on the cornea. A marginal ulcer 
in phlyctenular keratitis, or in acute blennorrhea, may serve 
the same end. The only objection to this theory of the 
causation of pterygium is that an ulcer is not always to be 
found at the head of the growth. 

Fuchs * believes that pterygium develops from the pinguec- 
ula, and that the latter causes nutritive changes in the cornea, 
loosening the superficial lamellae, and allowing the connective 
tissue of the limbus to grow in. 

Pterygium is a rare affection in this country, but is more 
common in countries or localities where the air is filled with 
fine sand or other minute particles. 

Treatment. — Unless the pterygium be very thick, and have 
invaded the cornea to some extent, or be progressing over the 
cornea, it is well to let it alone ; the more so as by removing 
it a quite normal appearance is not given to the eye, for a 

* Von Graefe^s Archiv, xxxviii, part ii, p. I. 



146 DISEASES OF THE EYE. 

mark is necessarily left both on cornea and conjunctiva. If 
it be progressive or very disfiguring it should be removed, 
other proposed modes of dealing with it being futile. This 
may be effected either by ligature or excision. 

In the method by ligature, a strong silk suture is passed 
through two needles. The pterygium being raised with a 
forceps close to the cornea, one needle is passed under it here 
and the other needle in the same way close to its base, the 
ligature being drawn half-way through. The thread is cut 
close behind each needle, thus forming three ligatures, which 
are respectively tied tight. In four or five days the pterygium 
comes away. 

For excision the apex is seized with a forceps and dissected 
off, either with a scissors or fine scalpel, care being taken not 
to injure the true cornea ; or a good plan is to pass a strabis- 
mus hook under the pterygium when raised up from the 
sclerotic, and to forcibly separate the corneal portion by draw- 
ing the hook under it. The dissection is continued toward 
the base of the pterygium, where it is finished with two con- 
vergent incisions meeting at the base. The mucous membrane 
in the neighborhood of the base is separated up somewhat 
from the sclerotic, and the margins of the conjunctival wound 
are then carefully brought together with sutures. Skin grafts, 
according to Thiersch's method, have been used with success 
to cover the defect. 

Pinguecula {p'mgms,/af) is the name given to a small 
yellowish elevation in the conjunctiva near the margin of the 
cornea, usually at its inner side, more rarely at its temporal 
margin, but sometimes in each place. It contains, notwith- 
standing its name, no fat, but is composed of connective tissue 
and elastic fibers. It is supposed to be due to the irritation 
caused by small foreign bodies. It rarely grows to a large 
size, and requires no treatment unless it becomes very dis- 
figuring, when it may be removed with forceps and scissors. 



THE CONJUNCTIVA. 147 

Subconjunctival Ecchymosis. — The rupture of a small 
subconjunctival vessel in the bulbar conjunctiva, without 
conjunctivitis, is of frequent occurrence. It suddenly gives a 
more or less extensive purple hue to the "white of the eye," 
causing the patient much concern. It is common enough in 
old people, but may occur in the young, and even in children, 
from severe straining, as in whooping-cough, vomiting, or 
raising heavy weights. It is occasionally significant of diabetes. 
It also occurs sometimes during epileptic fits, and profuse sub- 
conjunctival hemorrhage is occasionally found in cases of 
fracture of the base of the skull, having made its way along 
the floor of the orbit. It is of no importance so far as the 
integrity of the eye is concerned. 

Treatment. — None is required, the extravasated blood 
gradually becoming absorbed. 

Nevus of the conjunctiva may occur along with the same 
condition of the lids, but it also occurs separately, especially 
on the plica or caruncle. 

Treatment. — Electrolysis or ligature. Good results have 
been obtained with ethylate of sodium carefully painted on.* 

Polypus of the conjunctiva, for which it is difficult to 
assign a cause, is sometimes seen. It is generally small, in 
connection with the semi-lunar fold or caruncle, and can 
readily be removed with the scissors. Granulations occur- 
ring after tenotomy for strabismus are sometimes, and incor- 
rectly, called polypi. 

Dermoid Tumors. — These are pale yellow in color, and 
in size from that of a split pea to that of a cherry. They are 
smooth on the surface, and sometimes have fine hairs, and sit 
usually at the outer and lower margin of the cornea ; but 
figure 50 was drawn from a case on which I operated, where 
the dermoid was situated on the inner side of the cornea, 

* Snell, Trans. Oph. Soc. Un. K., Vol. xiii, p. 39. 



148 DISEASES OF THE EYE. 

extending over somewhat on the latter, and not at the most 
usual seat. In structure they resemble that of the skin. 
They are congenital tumors, supposed to be due to an arrest 
in development, but they often have a tendency to extend over 
the cornea. If this tendency be present, the tUmor must be 
removed by dissecting it off the cornea, care being taken not 
to go into the deep layers of the latter. 

Lipoma occurs as a con- 
;.^ ;■ % genital subconjunctival forma- 

tion of fat, usually situated 
between the superior and ex- 
ternal recti muscles. 

Syphilitic disease of the 
conjunctiva occurs both as 
primary and as secondary dis- 
ease. It will be treated of in 
^jQ -Q chapter vi, on Diseases of the 

Eyelids. 
Papilloma, or Papillary Fibroma. — This is a non-malig- 
nant growth, which may spring from any part of the conjunc- 
tival sac. It appears in the beginning as a small, round, red 
knob. The papillomata growing from the tarsal conjunctiva 
and from the semi-lunar fold, frequently take on a cauliflower 
appearance ; while on the bulbar conjunctiva and in the fornix 
the growths are liable to be pedunculated, with a papillary 
surface. The limbus of the conjunctiva is a favorite seat for a 
papilloma, and in the early stage it may be impossible to dis- 
tinguish it from an epithelioma. But if the case come under 
observation at a later stage, when the growth has overlapped 
the cornea, this difficulty does not arise, for the papilloma 
merely lies on the cornea, and can be lifted freely off it with a 
probe, while the epithelioma infiltrates the corneal tissue. 

Treatinent. — Thorough removal with knife or scissors, and 
actual cautery, as otherwise the growth is liable to recur. 




i 



THE CONJUNCTIVA. 149 

Epithelioma is not common as a primary disease of the 
conjunctiva. When it is so found it is seen as a Httle non- 
pigmented tumor growing from the Hmbus of the conjunctiva, 
surrounded by vascularization, and may in this stage be mis- 
taken for a phlyctenula, of which, however, the margins are 
not so steep, or for a papilloma (vide supra). As the tumor 
increases in size it becomes lobulated and ulcerates, and soon 
attacks the cornea, giving rise, on the latter, to an appearance 
very like pannus. The neighboring lymphatic glands become 
enlarged. The so-called coccidia, w^hich have lately been dis- 
covered in epithelial cancers, have also been observed in these 
tumors.* 

Sarcoma, too, is rare, and also takes its origin in the 
limbus conjunctivae. It is usually a pigmented tumor, a 
melanosarcoma. It does not attack the cornea so readily as 
the epitheliomatous growths, although it often overlaps the 
surface of the cornea. In its later stages this tumor grows 
to an enormous size. That these sarcomata are pigmented is 
explained by the fact that the limbus contains pigment, 
although usually so slight in amount as not to be visible to 
the naked eye. 

Treatment. — Both epithelioma and sarcoma of the conjunc- 
tiv^a demand prompt operative removal in order to prevent an 
extension of the growth to the rest of the eye, if the case be 
seen early, as well as to avert metastases to other organs. 
The knife and actual cautery may save the eye and the life in 
the early stages, but later on removal of the whole eye is 
often called for. 

Sim'ple cysts of the conjunctiva are very rare. They appear 
as clear spheric protuberances of about the size of a pea, 
seated usually on the bulbar conjunctiva. The walls of the 
cysts contain but few vessels, are thin and almost transparent, 

■^Lagrange, " Etudes sur les Tumeursdel'CEil, de I'Orbite," etc., Paris, 1839. 



ISO DISEASES OF THE EYE. 

while for contents they have a clear limpid fluid. These cysts 
cannot, as a rule, be moved from their position, because they 
are adherent to the conjunctiva, which, indeed, takes part in the 
formation of their walls. They are, very probably, dilated 
lymphatic vessels. Small bead-like strings of dilated lym- 
phatics are very frequently seen on the bulbar conjunctiva. 

These simple cysts are most commonly congenital, but they 
may begin to be developed during life. 

Treatment. — The cyst may be dissected out, or it may be 
sufficient to abscise its anterior wall. 

Subconjunctival cysticercus is a little more common than 
simple cyst of the conjunctiva, and yet only 46 examples of it 
have been placed on record.* 

Cysticercus is distinguished from simple cyst by its free 
mobility under the conjunctiva, to which it is not attached ; by 
its thicker and more vascular walls ; and, above all, by the 
presence of a round, white, opaque spot on the anterior surface, 
first pointed out by Sichel, and looked on by him as pathog- 
nomonic of a cysticercus. This spot indicates the position 
of the receptaculum, and, occasionally, when this comes to 
be placed on the posterior surface of the cyst, it may be diffi- 
cult or impossible to make the diagnosis with certainty. 

Treatment. — The cyst maybe pushed to one side under the 
conjunctiva, an incision made in the latter, the cyst then pushed 
back again, and out through the opening. 

Lithiasis consists in the calcification of the secretion of the 
Meibomian glands, which are seen as little brilliantly white 
spots, not larger than a pin's head, in the conjunctiva. There 
may be one only or very many. These concretions often g\\^ 
rise to much conjunctival irritation, and if they protrude over 
the surface of the conjunctiva may injure the cornea. Each 



* L. Werner, " Subconjunctival Cysticercus," Tf'ans. Ophthal. Soc, ix, p. 74. 
The literature of the subject is here fully given. 



THE CONJU^XTIVA. 151 

one, the eye having been cocainized, must be separate!}' re- 
moved by a needle, with which first an incision has been made 

into the conjunctiva over the concretion. 

Uric acid deposits have been seen in the palpebral con- 

juncti\a in gouty cases. They occur more frequently than is 
supposed, and gWc the murexid reaction."^ 

Injuries of the Conjunctiva. — Foreign bodies frequently 
make their way into the conjunctival sac and cause much 
pain, especially if they get under the upper lid, by reason, 
chiefly, of their coming in contact with the corneal surface 
during motions of the lid and of the e}"e. If the foreign body 
be under the lower lid, it Avill be easily found on drawing down 
the latter, and, pro\'ided it be not actual!}' imbedded in the 
mucous membrane, it is easih' removed witli a camel' s-liair 
pencil, or with the corner of a soft pocket-handlcerchief ; but 
if the foreign bod}- be under the upper lid, it is necessary to 
evert the latter before it is reached. Should the foreign bod}^ 
be imbedded in the conjuncti\-a, it must be pricked out of its 
position with tlie point of a needle or other suitable instrument, 
and the little proceeding will be made easier, both for patient 
and surgeon, b}' the instillation of a few drops of solution of 
cocain (two per cent.) into the e}'e.t 

The conjunctiva is frequent!}' injured in severe wounds of 
the e}'e!ids or eyeball. The interest and treatment are centered 
here chiefl}- on the other more important parts which ha\-e 
been injured. A tear or wound of the conjunctiva, usually of 
the bulbar portion, when it occasional!}' occurs without in- 
jun' to other parts, is in general of ver}- sliglit moment. If 
the wound be extensive its edges should be drawn together 



* Trans. Clin. Soc, London, January, 1893. 

t The continuous or frequently recurring sensation of a foreign body in the 
conjunctival sac, while nothing of the kind, nor any hyperemia is present, is 
sometimes a premonitory sign of mental disease. 



152 DISEASES OF THE EYE. 

with a few points of suture, but otherwise heahng will take 
place with the aid simply of a bandage to keep the eye closed 
for a few days. 

A common form of injury, which may involve the con- 
junctiva alone, is a burn by acid or lime. In the case of a 
strong acid getting into the eye, if the patient be seen imme- 
diately after the occurrence, the whole conjunctival sac should 
be well washed out with an alkaline solution, while in the 
case of lime a weak solution of a mineral acid is indicated for 
the purpose. Cocain may be employed to relieve the pain. 
Subsequently, protection of the eye with the use of olive- or 
castor-oil dropped into it will best promote the healing pro- 
cess. 

In the case of a severe burn of the conjunctiva, the result- 
ing cicatrix is liable to produce a more or less extensive union 
of the eyelid to the eyeball (symblepharon), which often in- 
terferes with the motion of the latter, or even with vision, if 
the cornea be obscured. No measures taken during the heal- 
ing process can prevent symblepharon, if the degree of the 
burn be such as to bring it about. The relief of symblepha- 
ron by operation will be dealt with in chapter vi, on Diseases 
of the Eyelids. 



CHAPTER V. 

PHLYCTENULAR, OR STRUMOUS, CONJUNCTI- 
VITIS AND KERATITIS.* 

Both from a clinical and nosologic point of view, it would 
be incorrect to divide this affection into two, under the heads 
of Diseases of the Conjunctiva and Diseases of the Cornea ; 
and, therefore, I treat of it here as one disease, and being a 
very important disease, I devote a special chapter to it. It is 
important, because it is excessively common, and because it 
is capable of causing considerable damage to sight. More- 
over, even when it occurs on the cornea, it should probably be 
regarded as a conjunctival disease, for the corneal layer, which 
it primarily attacks, is the epithelium, and this, — if not also, as 
some authors state. Bowman's membrane and the anterior 
layers of the true cornea, — as we know from the fetal devel- 
opment of the membrane, is a continuation of the conjunctiva 
in a modified form over the cornea, f 

Horner J termed it eczema of the conjunctiva and cornea. 
It is characterized by the eruption of phlyctenulse {iflvv-avm^ 
a vcsich\ or pustule) on the conjunctiva bulbi (but never on 
the palpebral conjunctiva), on the conjunctival limbus, or on 
the cornea, and is chiefly a disease of children up to the eighth 
or tenth year of age. 

* Kepac, a horn. 

t The posterior epithelium, or even, according to some, this along with the 
membrane of Descemet and the posterior layers of the true cornea, is to be 
reckoned to the uveal tract ; while the true cornea, or, according to some, only 
its central layers, is a modification of the sclerotic. 

i Loc. ciL, Bd. V, Abth. ii, p. 279. 

13 153 



154 DISEASES OF THE EYE. 

Notwithstanding the derivation of the word, a phlyctenula, 
or phlyctene, is originally neither a vesicle nor a pustule ; but 
when on the conjunctiva is a solid elevation, consisting of a 
collection of lymph-cells, and is of a grayish color. In a late 
stage, or under unsuitable treatment, the phlyctenula may, it 
is true, become a pustule. On the conjunctiva two types of 
the disease can be recognized : 

1. The Solitary, or Simple, Phlyctenula. — Of this there 
may be one or several, varying in size from one mm. to four 
mm. in diameter. The vascular injection is immediately 
around the phlyctenula, and is not diffused over the conjunc- 
tiva. At first there may be shooting pains and lacrimation, 
but these soon pass away. If the phlyctenulae be not seated 
close to the cornea the affection is not serious, and the length 
of time required for its cure depends on the size of the phlyc- 
tenulae, varying from seven to fourteen days, as a rule. 

2. Multiple, or Miliary, Phlyctenulse. — These are very 
minute, like grains of fine sand, and are always situated on 
the limbus of the conjunctiva, which is swelled. The general 
injection and swelling of the conjunctiva are considerable, and, 
occurring as it does almost exclusively in young children, the 
affection may be called eczematous conjunctival catarrh of 
children (Horner). The irritation and so-called photophobia 
and lacrimation are often considerable, and there is a good 
deal of conjunctival discharge. This form is very apt to 
appear after measles and scarlatina. 

BotJi forms are liable to extend to the cornea, and then onl}' 
does the disease become serious. This event may come 
about in the following different ways : 

The solitary phlyctenula may be seated partly on the 
limbus conjunctivae and partly on the margin of the cornea, 
and may undergo resolution. 

Or it may give rise to a deep ulcer, which either heals, 
leaving a scar, or perforates, causing prolapse of the iris, etc. 



PHLYCTENULAR OPHTHALMIA. 155 

Or it may form the starting-point of a progressive ribbon- 
like keratitis (fascicular keratitis), the pustule becoming an 
ulcer, at the margin of which the corneal epithelium is raised 
and infiltrated in crescentic shape. This now steadily ad- 
vances for many weeks toward the center of the cornea, fol- 
lowed by a leash of vessels which has its termination in the 
concavity of the crescent. The process is accompanied by 
m.uch irritation of the terminal branches of the fifth nerve in 
the cornea, and the consequent reflex blepharospasm. A 
permanent mark indicates the track of the ulcer. 

The multiple miliary phUxtenulae on the limbus conjunc- 
tivae may cause some slight superficial infiltration and vascu- 
larization of the cornea in their immediate neighborhood, 
which pass off when the phlyctenulae disappear. 

Or they may be accompanied by deeper marginal infiltra- 
tions of the cornea, which become confluent and result in an 
ulcer that extends along the margin of the cornea for some 
distance, and is termed a ring ulcer. It is a serious form of 
ulcer, for if it extend far round it may destroy the cornea in 
a few days b}^ cutting off its nutrition. 

Primary phlyctenular keratitis occurs principally in three 
different forms : i. Very small gray sub-epithelial infiltrations, 
which are apt to turn into small ulcers, and then heal, leaving 
a slight mark. This mark may ultimately quite disappear, 
especially in the case of children, and when situated peripher- 
ally. 2. Somewhat larger and deeper infiltrations, resulting 
in ulcers of corresponding size, which heal by aid of vasculari- 
zation from the margin of the cornea. The opacity left after 
these ulcers is rather intense, and clears up but little, espe- 
cially if the situation be central. 3. Large and deep-seated 
pustules, often at the center of the cornea, give rise to large 
and deep ulcers, which may be accompanied by hypopyon 
and even by iritis, and which frequently go on to perforation. 

Photophobia is usually a prominent symptom in phhc- 



Ii6 



DISEASES OF THE EYE. 



tenular keratitis. The term photophobia, however, is not 
altogether correct, for it is the fifth nerve, from the cornea, 
which is mainly the afferent nerve here rather than the optic 
nerve. This is evident from the fact that in the dark the 
patient does not get complete relief. The explanation of this 
reflex blepharospasm has been given by Iwanoff,* who showed 
that the round cells, in making their way from the margin of 
the cornea to their position under the epithehum, follow the 
course of the nerve filaments, which they irritate in their 



-^ 




-I> 



~^- C 



Fig. 51. 

E. Epithelium. B. Ant. elastic lamina. C. True cornea. A^. Nerve filament, 

with lymph-cells on its course. D. Phlyctenula. 

progress. The accompanying figures, 51 and 52, are from his 
original paper. 

Eczema of the eyelids, face, and external ear, and catarrh 
of the Schneiderian mucous membrane, frequently accompany 
phlyctenular conjunctivitis and keratitis. 

In these cases, in children of three or four years of age, 
temporary amaurosis has sometimes been observed after a 



Klin. Monatsbldtter f. Augenheilkicnde, 1869, p. 465. 



PHLYCTENULAR OPHTHALMIA. 



157 



severe and long-continued blepharospasm has passed away. 
The patient is found to be unable to see even large objects, 
or to find his way, although the pupil reflex is active, and 
a strong light may still be distressing. There are no ophthal- 
moscopic appearances. This blindness passes away com- 
pletely in from two to four weeks. It has been regarded as 
a reflex phenomenon, and again it has been held to be due 
to disturbance of the intraocular circulation from pressure of 
the eyelids on the eyeball. But the view (Leber, Uhthoff) 
w^iich represents it as having a central cause is probably the 
correct one. It is likely at this tender age, when the psycho- 




FiG. 52. 



physical processes are not as yet firmly established, that the 
desire not to see, and the active withdrawal from the act of 
vision, leads in a short time to a functional paralysis of the 
visual centers in the brain, and that these take some time to 
recover or to relearn their functions when the ground for the 
suspension of the latter has ceased. 

Cause. — This is a disease of childhood, although it is rare 
in the very first year of life. In adults it is uncommon. 

The strumous constitution, as indicated by the swollen nose 
and upper lip, and sometimes by the enlarged lymphatics in 
the neck, as well as by the eczema just mentioned, is that 
most liable to this affection. Often, however, it will be found 



IS8 DISEASES OF THE EYE. 

in strong children with apparently perfect general health, but 
even in them there is probably some allied irregularity of nu- 
trition, of which the great tendency to recurrence of the eye 
affection is evidence. 

Colonies of straw-colored micrococci may be found in the 
contents of the phlyctenulae, but what etiologic relationship 
to the production of the phlyctenulae they possess is not yet 
known. 

Treatment. — The solitary phlyctenula is best treated with the 
yellow oxid of mercury ointment in the strength of i 5 grs. to 
5j of benzoated lard, of which the size of a hemp-seed should 
be put into the eye once a day. Or a small quantity of pure 
calomel dusted into the eye once a day will also cure ; but this 
remedy should not be employed if iodid of potassium is being 
taken internally, for then iodid of mercury is liable to be 
formed in the conjunctiva. 

The miliary phlyctenular conjunctivitis is best treated at first 
with cold or iced applications. Freshly prepared chlorin water 
(one part liq. chlori., nine parts water), to be dropped into the 
eye once a day, is recommended by some, and later on, liq. 
plumbi dil. or sol. argent, nitr. (grs. v ad oj, and neutralized), 
applied to the everted conjunctiva ; or, if the phlyctenular 
appearance predominate over the catarrhal, the yellow oxid 
of mercury ointment or insufflations of calomel may be pre- 
ferred. I myself rarely employ any remedy other than the 
two latter, which I find applicable to all these cases. 

When the cornea is slightly affected near the margin in cases 
of miliary phlyctenulae, calomel, or the yellow oxid of mercury 
ointment, and warm fomentations, should be used. 

Where a large pustule on the margin of the cornea has re- 
sulted in a deep ulcer, with tendency to perforate, and ac- 
companied by much pain, I cannot too highly recommend para- 
centesis of the anterior chamber through the floor of the ulcer, 
the pupil having first been brought well under the influence of 



PHLYCTE^X'LAR OPHTHALMIA. 159 

eserin to prevent prolapse of the iris. The good effect of this 
will be very soon apparent : the pain disappears, the patient 
sleeps, the ulcer becomes vascularized, and healing sets in. 
Cauterization of the ulcer in an early stage with the galvano- 
cautery is also good practice, but in these cases I prefer the 
paracentesis. Man}' surgeons trust very much to eserin, warm 
fomentations, and a pressure bandage. 

For the fascicular keratitis the yellow oxid of mercury oint- 
ment is in its place. When the crescentic infiltration is very 
intense it is well to touch it with the galvano-cautery. Division 
of the leash of vessels at the margin of the cornea has a bene- 
ficial effect. 

For the ring ulcer a pressure bandage, under which an 
antiseptic dressing (boracic or salicylic acid, or perchlorid of 
mercur}') has been placed, is, perhaps, the best method of treat- 
ment. Warm fomentations promote \"ascular reaction, and may 
be used with benefit at each change of bandage. 

For primary phlyctenul^e of the cornea in the form of the 
minute gray superficial infiltration or ulcer, nothing beyond 
atropin, with warm fomentations, and a protective bandage to 
keep the eyelids quiet, should be used. When reparation of 
the ulcer has commenced, calomel or weak yellow oxid of 
mercury ointment may be employed. 

For the large purulent phlyctenula, resulting in a large and 
deep ulcer, often situated at the center of the cornea, with 
hypopyon and iritis, warm fomentations (camomile, or poppy- 
head, at 90° F., for twent}- minutes three times a day), 
atropin, boric acid as ointment or powder, and a protection 
bandage form the treatment in the early stages. Here, also, 
I often puncture the ulcer, with the very best results in respect 
of hastenincT- the cure, and the cralvano-cauter\- mav be used 
with advantage. In the stage of reparation, Pagenstecher's 
ointment or insufflations of calomel are verv useful. 



l6o DISEASES OF THE EYE. 

In all forms of phlyctenular ophthalmia those favorite rem^ 
edies, blisters, setons, and leeching should be avoided. The 
first two worry the patient, give rise to eczema of the skin, 
and are not to be compared in their power of cure with the 
measures above recommended ; while leeching gives, at best, 
but temporary relief, and deprives the patient of blood which 
he much requires. 

For relief of the blepharospasm, in addition to the use of 
atropin, plunging the child's face into a basin of cold water is 
a most efficacious means. The face is kept under the water 
until the child struggles for breath, and this immersion is re- 
peated two or three times in rapid succession, and used every 
day if necessary. It should always be used where the blepharo- 
spasm is severe, as the latter is not only distressing to the 
patient, but also an obstacle to the cure. 

The general treatment, notwithstanding the so-called photo- 
phobia, should consist in open-air exercise before everything 
else ; unless, indeed, there be an ulcer which threatens to 
perforate. It is not well to keep the patient's face or eyes 
covered with bandages and shades, nor to confine him to a 
dark room. A pair of dark blue glasses are the best protec- 
tion from strong glare of light, and shady places can be 
selected when the patient is out of doors. Cold or sea-baths, 
followed by brisk dry rubbing. Easily assimilated food at 
regular meal hours, but no feeding between meals. Regula- 
tion of the bowels. Internally : cod-liver oil, maltine, iron, 
arsenic, syr. phosph. of lime, and such-like remedies are 
indicated. 

The great tendency to recurrence is one of the most trouble- 
some peculiarities of all kinds of phlyctenular ophthalmia ; 
and in order to prevent this, so far as possible, it is important 
to continue local treatment until the eye is perfectly white on 
the child's awaking in the morning, and even for fourteen days 



PHLYCTENULAR OPHTHALMIA. i6i 

longer. This prolongation of the treatment will also assist 
in clearing up opacities, as best they may be. For this after- 
course of treatment, calomel insufflations should be used. 

Nothing can be done for the opaque scars left on the cornea 
by ulcers when all inflammatory symptoms have subsided. If 
the ulcer has been very superficial, the resulting scar in young 
children may disappear in the course of time. Deep ulcers 
cause more opaque and permanent scars, and ulcers which 
have perforated produce the greatest opacity. Some of the 
very disfiguring scars may be tattooed. (See Chap, vi.) 

The degree of the defect of vision to which an opacity of 
the cornea may give rise depends, in the first instance, on 
the position of the opacity. If it be peripheral, the vision may 
be perfect, but if it be in the center of the cornea sight may 
be seriously damaged. Even a slight nebula, barely visible to 
the observer, will cause serious disturbance of vision if situated 
in the center of the cornea ; while, in the same situation, the 
very opaque scar of a deep ulcer will produce a proportionately 
greater defect. If a central, but not deep, ulcer should not 
become completely filled up in healing, and a facet remain, 
vision will also suffer much in consequence of irregular refrac- 
tion, although there may be but little opacity. 



14 



CHAPTER VI. 

DISEASES OF THE CORNEA. 

The importance of a knowledge of the diseases and injuries 
of the cornea depends on their great frequency, coupled with 
the fact that nearly every one of them is liable to leave behind 
it some opacity, with resulting defect of sight and disfigure- 
ment of the eye, while several of them are very apt to lead to 
complete loss of sight. 

Inflammations of the Cornea. 

From a clinical point of view these will be most conveni- 
ently considered under the headings : (a) Ulcerative Inflam- 
mations, and (d) Non-ulcerative Inflammations. 

(a) Ulcerative Inflammations of the Cornea. — Before 
an ulcer can form in the cornea there must be a cellular in- 
filtration of its tissue near its anterior surface ; and this cellu- 
lar infiltration is brought about, we nowadays believe, by the 
entrance into the cornea of certain microorganisms, the 
gonococcus, or the staphylococcus pyogenes, or other as 
yet undescribed forms. One recognizes the existence of an 
infiltration by seeing an opaque spot in the cornea, with a 
dulness of the layers over it, and often of the corresponding 
part of the epithelium. Before long the epithelium covering 
the infiltration comes away, and soon the intervening layers 
of the true cornea break down, and then we have an ulcer 
established. 

But although all ulcers of the cornea originate in an infil- 
tration, yet when once established they take on a great variety 

162 



THE CORNEA. 163 

of type, in consequence, it may be, of a variety in the nature 
of the originating micrococcus. Some ulcers are purulent, 
others non-purulent ; some tend to spread over the surface 
of the cornea, others tend to go deep into it ; some attack by 
preference the central region of the cornea, while others are 
confined to its margin ; some readily give way to treatment, 
and others are very obstinate or almost incurable. Again, 
some ulcerative corneal processes are attended by much circum- 
corneal injection, severe pain in and about the eye, great reflex 
blepharospasm, and lacrimation ; whilst others, which may 
really be more severe processes in so far as the integrity of 
the eye is concerned, can run their course with scarcely any 
injection of the eyeball, and with little or no distress to the 
patient. 

Etiologically , corneal ulcers are primary or secondary. The 
primary ulcers are those in which the diseased process origi- 
nates in the cornea, most commonly as the result of traumata, 
but also in phlyctenular keratitis, or as the result of corneal 
abscess, or where the nutrition of the cornea is interfered with, 
etc. Secondary ulcers are those which are the result of disease 
elsewhere, usually in the conjunctiva, as in acute blennorrhea 
and in conjunctival diphtheritis. 

Corneal ulcers are more common in advanced than in early 
life. Indeed, in early life, unless in cases of blennorrhea 
neonatorum, and of phlyctenular disease, corneal ulcers are, I 
may say, unknown. The greater liability to these affections 
in advanced life is due, no doubt, to a less active nutrition at 
that period in this already lowly organized part. Hence 
slight traumata, or the presence of a slight conjunctival catarrh, 
which would have no ill effect in a young person, may form 
the starting-point of a corneal ulcer in an old person or even 
in one of middle age. For the same reasons corneal ulcers 
are much more common in the lower orders than amongst the 
well-to-do, for the general nutrition of the poor is often de- 



i64 DISEASES OF THE EYE.. 

fective, while they are more exposed to traumata than are the 
better classes. 

The diagnosis of the presence of a large corneal ulcer is 
very simple. Inspection of the cornea in ordinary daylight 
at once reveals the loss of substance, more or less extensive, 
deep, and infiltrated. If the ulcer be very small and shallow 
the difficulty is greater, especially if there be much blepharo- 
spasm. In such cases the surgeon must endeavor to inspect 
the cornea from different points of view, either by directing 
the patient to move his eye, or by moving his own head, until 
he succeed in obtaining such an incidence of the light as will 
display the minute loss of substance, with its margin, and more 
or less gray infiltrated floor ; or he may employ the oblique 
illumination with artificial light. An instillation of cocain 
may be necessary to facilitate the examination by diminishing 
the blepharospasm. 

It is obviously important to decide at the outset whether 
a gray spot in the cornea be an infiltration (= a collection of 
cells which may shortly become an ulcer), an ulcer, or a scar 
(= a healed ulcer, or other loss of substance). The surface 
covering an infiltration, although flush with the general surface 
of the cornea, has usually a steamy appearance, due to some 
disorganization of the corneal epithelium, and has no polish. 
With an ulcer the appearances above described will be found. 
The surface of a scar is usually, although not always, flush 
with the general surface of the cornea, and it is a polished 
surface — i. e., covered with normal epithelium, not rough, 
irregular, nor even steamy. 

A very beautiful method for ascertaining the presence and 
true extent of a corneal ulcer or traumatic loss of substance 
is the instillation of a two per cent, solution of fluorescin. 
Almost immediately afterward the tissue forming the floor of 
the loss of substance assumes a greenish tint, which clearly 
differentiates it from the surrounding normal cornea. 



THE CORNEA. 165 

The presence oi Jiypopyon {pr.6^ under ; -uov, pus) is the rule 
with some types of corneal ulcer. Hypopyon is a deposit of 
pus in the anterior chamber, and as the patient sits or stands 
it lies in the lowest part of the chamber, to which place it 
has gravitated. If the patient lie in bed — say, on the side of 
the affected eye — the hypopyon will, of course, change its 
position, and gravitate toward the outer side of the chamber. 
Sometimes the hypopyon is so small as to be detected with 
difficulty ; and again it may fill the whole anterior chamber, 
completely obscuring the iris. It will be asked : From 
whence does the pus come w^hich forms hypopyon in cases 
of corneal ulcers ? It might be supposed that it is derived 
directly from the purulent floor of the ulcer, by passage of 
the pus-cells through the posterior layers of the cornea. 
But this is not so. No pus-cells do, or indeed can, pass 
through the membrane of Descemet, Moreover, copious hy- 
popyon is often present when the corneal ulcer is quite small 
and non-purulent. The pus-cells which form h}'popyon in 
cases of corneal ulcer come from the iris, in compliance with 
the law which causes leukocytes to wander out of blood-vessels 
in the neighborhood of an inflammatory focus, and to make 
their way toward that focus. When these leukocytes from the 
iris reach the anterior chamber they can go no further, owing 
to the barrier imposed to their progress by the membrane of 
Descemet. 

The pus forming a hypopyon contains, in its early stages at 
least, no microbes. These interesting facts concerning the 
genesis and nature of hypopyon have been discovered by 
Professor Leber.* 

The dangers attendant upon corneal ulcers are, first of all, 
the opacities, the scars, which even the slightest of them are 
apt to leave behind. 

* "Die Entstehung der Entziindung," Leipzig, 1891. 



i66 



DISEASES OF THE EYE. 



Figure 53 represents a section made through a deep ulcer 
in its progressive stage. At the margin of the ulcer the epi- 
thelium (£') and Bowman's membrane {b) cease. The floor 
of the ulcer is seen covered with pus, which also infiltrates 




Fig. 53. — [Ftichs.) 



the corneal tissue in the neighborhood. As soon as cure 
commences, the floor of the ulcer begins to get clear — /. e., it 
becomes gradually less covered with pus — until it is finally 
quite free from it, and pari passu the surrounding infiltra- 




FiG. 54. — {Ft(c/is.) 



tion is absorbed 

margin {in ;;/, Fig. 54) all around 



Then the epithelium, growing in from the 



gradually carpets • over 
the floor of the ulcer, and underneath this newly-formed 



THE CORNEA. 167 

epithelium the new tissue, which is to close the loss of sub- 
stance, is laid down. This new tissue, however, is not corneal 
tissue, but is ordinar\' connective tissue, and is therefore 
opaque. Hence the deeper the ulcer has been, the more in- 
tense will be the resulting opacit}-. Bowman's membrane 
never becomes restored over the cicatrix. 

The ulcers which are situated at the center of the cornea, 
in the pupillar\- area, are more serious for sight than those 
situated peripherally, as can be readily understood. The 
opacit}* left b}' a ver\- superficial ulcer is slight, and is called 
a nebula ; a somewhat more intense opacity is called a macula ; 
and a very marked white scar is called a leukoma. 

But a more serious danger connected \\ith ulcers of the 
cornea than the opacities they leave behind is that of perfora- 
tion of the cornea, to which some ulcers are very prone. For 
an account of the consequences of perforation seepages 133, 
171. and 194 (on staphyloma of the cornea). 

In the treatment of primary corneal ulcers the student will 
soon perceive that a bandage, atropin. and warm fomentations 
pla}' prominent parts. 

The bandage should be put on with firm pressure — but 
should not be made uncomfortabh' tigrht — the eve having been 
previously padded out. especially at the inner canthus, so that 
equal pressure ma\' be exercised on the globe all over. The 
support thus given to the cornea and front of the e\-e promotes 
the healing process in the ulcer, and the bandage is also useful 
by preventing the e\-elids from rubbing over the ulcer, and by 
keeping small foreign bodies from it. In secondary ulcers, 
due to severe conjunctival processes, such as blennorrhea, a 
bandage is contraindicated, because it retains the secretion, 
and therefore would do more harm than good. 

Atropin. in sufficient quantities to keep the pupil dilated, 
should be employed. Iritis very often attends severe corneal 
ulcers, and here the indication for atropin is obvious. But rest 



i68 DISEASES OF THE EYE. 

of the affected part is, we know, an important element in pre- 
venting or in curing any inflammation ; and in the affections 
we are now treating of, even where there is no iritis, atropin 
acts by procuring rest of the iris and of the cihary muscle, 
the constant motion of which would otherwise tend to aug- 
ment the inflammatory process in the cornea. 

Some surgeons use myotics (eserin or pilocarpin) in pref- 
erence to atropin in the treatment of corneal ulcers. They 
hold that their power of reducing the intraocular tension en- 
courages healing of the ulcers, while they also think the 
more extended surface of iris presented facilitates absorption 
of the hypopyon. But it is doubtful whether myotics do 
reduce the normal tension, although they often have that effect 
upon abnormal tension, and my objection to them in these 
cases is that they increase, I believe, the tendency to iritis. 
Absorption of the hypopyon will only come about when the 
cornea begins to recover, whatever the treatment may be. 
I am not singular in this view of the use of eserin in corneal 
ulcers. An indication for myotics, however, is given by the 
presence of an ulcer near the corneal margin with a tendency 
to perforate, for here the myosis would assist in preventing 
prolapse of the iris should perforation take place. 

Warm fomentations promote the healing process by stimu- 
lating tissue changes in the cornea. One usually orders them 
to be made with poppy-head water or camomile tea, although, 
no doubt, warm water would be equally efficacious. Hot 
solutions of four per cent, boracic acid, or i : 5000 corrosive 
sublimate, may be used with advantage. The bandage having 
been removed, a compress of lint dipped in the stupe at about 
120° F. is laid upon the eye, and frequently replaced by fresh 
compresses out of the stupe, so that the one on the eye may 
be always hot. This is continued for half an hour at a time, 
and repeated every two or three hours. 

In an ulcer of a purulent or sloughing nature the insuffla- 



THE CORXEA. 



169 



tion on its floor of very finely divided iodoform powder is 
useful. 

Thorough scraping of the floor of the ulcer f 

Avith a small, sharp spoon is a very important { J, 

and valuable method. 

The actual cautery has of late \-ears come 
much into use in the treatment of purulent and 
serpiginous corneal ulcers. It acts by destroy- 
ing the microorganisms which keep the process 
going. Either a thermo-cauter}-. in the form of 
a veiy fine point, or the galvano-cauter>- (Fig. 
55) maybe employed. To the latter a medium- 
sized bichromate of potash bottle-battery is 
attached, and the platinum wire brought to a 
red heat. The eye having been cocainized, the 
red-hot cauteiy is brought into contact with the 
whole surface of the ulcer, so as to thoroughly 
destroy its superficial layer, and special atten- 
tion is paid to any part of the margin of the 
ulcer where it seems inclined to spread to as 
}-et health}- tissue. Fluorescin may be used to 
show the extent of the ulcerated surface. The 
cauterization can be repeated as often as the 
progress of the ulcer makes it desirable. It is 
well to perforate the cornea ^^ith the cautery, 
and to evacuate the aqueous humor and h\"po- 
pyon ; or this may be done with an ordinary 
paracentesis needle after the cauterization is 
completed, ^ly own experience of the cauter}- h ^ 
in these cases is extremelv satisfacton*. It 



Fig. 55. — The bolt A being pushed forward, the current is 
completed, and passes through the platinum wire which 
forms the cautery. By pressure on the button B the cur- 
rent can be momentarily intercepted during use of the 
instrument. 



m 



Fig. 



lyo DISEASES OF THE EYE. 

seems to give the best percentage of cures with the least 
amount of opacity. 

Snellen and others prefer scraping to the cautery, on the 
ground that the former does not injure the healthy tissue as 
the latter may do. After scraping he touches the 
surface of the ulcer with tincture of iodin. 

Paracentesis of the anterior chamber through the 
floor of the ulcer is another most valuable therapeutic 
measure for some corneal ulcers, and deserves a more 
routine application in these cases than is at present 
accorded to it, the more so as the valuable httle opera- 
tion is simple and dangerless. But there are, I think, 
two imperative indications, two golden rules, for its 
use, namely : i. If there be great pain. Very shortly 
after the operation, which for the moment increases 
the neuralgia, the patient experiences the greatest 
relief, and passes the first good night after many 
wakeful ones, 2. If perforation seem to be imminent. 
This may often be recognized by a bulging forward of 
the thin floor of the ulcer ; but sometimes it is not 
easily foreseen, and if there be any doubt on the point 
paracentesis should be performed. It is important to 
forestall spontaneous perforation of the ulcer by this 
proceeding, because the opening made by the latter 
being linear it heals easily, and leaves but a slight scar 
without anterior synechia ; while the natural opening 
would be a complete loss of substance, and, therefore, 
Fig. 56. the more readily involve adhesion of the iris in the re- 
sulting comparatively extensive cicatrix. Other indi- 
cations for the operation are increased tension and the pres- 
ence of a large hypopyon. 

Paracentesis of the anterior chamber is best performed by 
means of a paracentesis needle (Fig. 56), which is a some- 
what shovel-shaped instrument, with a shoulder or stop. If 



THE CORNEA. 171 

this be not at hand a small iridectomy knife or a broad 
needle will answer the purpose. The eye having been 
cocainized, a spring-lid speculum is inserted, the eye fixed 
with a fixation forceps, and the point of the paracentesis 
needle applied to the floor of the ulcer in such a way that the 
plane of the little blade may be at an angle of about 45° 
with that of the floor of the ulcer. The point is pushed 
gently through the floor, and the plane of the blade is then 
immediately changed, so that, as the instrument is being 
advanced up to the shoulder, it may be almost in contact 
with the posterior surface of the cornea. The withdrawal 
of the instrument should be effected with extreme slowness, 
in order that the aqueous humor may flow off gradually, and 
not with a rush. If these precautions be taken there need 
be no danger of injuring the crystalline lens, of causing 
intraocular hemorrhage, or of having prolapse of the iris in 
the incision. If the latter should occur it can usually be 
reposed with the spatula. It may happen that when the 
needle has been quite withdrawn a considerable portion of 
the aqueous humor may still remain in the anterior chamber, 
unable to escape owing to the valve-like closure of the wound. 
It should be evacuated by making the wound gape by gentle 
pressure with a spatula on its posterior lip. If it be desirable 
to tap the anterior chamber on the next day, it can be done 
by simply opening up the wound with a spatula, or with the 
probe-like instrument at the other end of the handle (Fig. 56), 
without the aid of any cutting instrument. 

If the case does not come under the care of the surgeon 
until perforation of the ulcer with prolapse of the iris has 
taken place, the very important question as to the best 
method of dealing with the condition is presented. The same 
question arises in other forms of perforating ulcer. If the 
loss of substance occupy one-third or more of the cornea, with 
correspondingly large prolapse of iris, little can be done 



172 DISEASES OF THE EYE. 

beyond the use of eserin, and here I would use eserin, to 
reduce the intraocular pressure, along with the application of 
a firm bandage, for in such cases the formation of a corneal 
staphyloma is almost inevitable. But if the ulcer and pro- 
lapse be small an attempt may be made to free the iris, so 
that no anterior synechia may form, and in order that the 
cicatrix may be flat, and not raised over the surface of the 
cornea, and, therefore, exposed to injury. The importance of 
such an attempt lies in the fact that a corneal cicatrix with 
iris entangled in it, not merely adherent to its posterior sur- 
face, affords a constant source of danger, especially if situated 
near the margin of the cornea ; for in such eyes sudden and 
uncontrollable purulent inflammation of the iris and choroid 
may come on after an apparently slight trauma, and end 
in total destruction of the eye. This event is due to septic 
infection reaching the interior of the eye through a superficial 
loss of substance, the direct result of the trauma. The 
surgeon's attention should therefore be directed to obtaining 
at least as flat a cicatrix as possible, or, still better, a non- 
adherent cicatrix. The practice which I, as well as many 
other surgeons, have commonly followed, is to draw the 
prolapsed portion of iris slightly forward with a forceps, and 
to snip it off level with the surface of the cornea, and then 
with a spatula to endeavor to free the iris from any adhesions 
it may have formed with the margin of the ulcer. Atropin 
or eserin, according to the position of the ulcer, is then 
instilled, and a bandage carefully applied. This proceeding is 
only of use when a fresh prolapse can be dealt with, before 
cicatrization sets in ; and the result is often satisfactory so far 
as the securing of a flat cicatrix is concerned, but an anterior 
synechia can rarely be avoided. 

Dr. da Gama Pinto has successfully employed the follow- 
ing method for obtaining a non-adherent cicatrix : Having 
abscised the prolapsed portion of iris as above, and freed all 



THE CORNEA. 173 

adhesions to the margin of the ulcer ^vith a spatula, he covers 
the opening in the cornea with a flap cut from the bulbar 
conjunctiva — and this flap should be twice as large as the 
opening, in order to admit of its shrinkage — and then pushes 
the flap into the opening with a blunt probe. A firm binocu- 
lar bandage is applied, but no iodoform. The eye is not 
dressed until the third day, when the anterior chamber is 
often found restored, the iris all in its proper plane, and the 
conjunctival flap healed into the ulcer. Ultimately all trace of 
the flap disappears, and an ordinary non-adherent corneal scar 
is presented. I have employed this method twice, and in each 
case with a good result. 

From time to time different types of corneal ulcers have 
been recognized and described, and the following are the chief 
of them : 

Simple Ulcer. — This may result from a slight trauma, or 
from the bursting of a phlyctenula. It presents the appear- 
ance of a minute and shallow depression, with a gray floor, on 
the surface of the cornea. There is circumcorneal vascularity, 
especially at that part of the corneal margin nearest to which 
the ulcer is situated ; the pupil is apt to be contracted, al- 
though iritis is not present ; and there is often a good deal of 
pain, lacrimation, and photophobia. 

Treatment and Proo;nosis. — The eve is to be bandao-ed, 
warm fomentations applied several times a day, and a drop of 
solution of atropin instilled night and morning. When of 
phlyctenular origin stimulation with the yellow oxid oint- 
ment is indicated. Cure, with slight opacity remaining, comes 
about in a week or ten days. But occasionally this form of 
ulcer may pass over to the deep ulcer. 

Deep Ulcer. — This is a purulent ulcer, and commences in 
a purulent infiltration of the cornea. It forms a tolerably 
deep pit in the cornea toward its center, the floor of the ulcer 
being covered with purulent deposit and detritus, and the cor- 



174 DISEASES OF THE EYE. 

neal tissue immediately surrounding it being somewhat infil- 
trated with pus. The ulcer is generally round, but it may 
assume any shape. Hypopyon is often present, and a marked 
tendency to iritis exists. The pain is usually very severe, 
violent frontal neuralgia being a common symptom. 

This ulcer has no great tendency to spread over the surface 
of the cornea, but has a very decided tendency to perforate 
through it. As it does not generally attain wide dimensions 
the perforation it may produce is small, and gives rise to a 
small adherent leukoma rather than to a staphyloma. 

Causes. — This form of ulcer is a frequent one in purulent 
conjunctivitis, and it may be caused by the lodgment of foreign 
bodies, and other injuries of the cornea. 

Treatment. — If the ulcer be due to a conjunctival process, 
the latter should be actively treated. 

If the cause be other than conjunctival, a pressure bandage 
to give support to the ulcer is important, and periodic warm 
fomentations are most beneficial. Atropin should be instilled 
several times daily. Antiseptic applications, especially iodo- 
form in finely divided powder, are useful. 

Paracentesis of the anterior chamber through the floor of 
the ulcer is a proceeding always followed by improvement in the 
condition of the eye, and is very important as a preventive of 
natural perforation. The actual cautery, too, is in its place 
here. 

Ulcus Serpens (Saemisch's Ulcer, Infecting Ulcer). — This, 
also, is a purulent ulcer, the characteristic of which is its ten- 
dency to extend over the surface of the cornea, especially in 
some one direction, rather than to strike deep into its tissue. 
Its position is chiefly central, and it presents a grayish floor, 
which is more intensely opaque at some places. One part 
of the margin takes the form of a curve, or of several 
closely placed curves, and at this place becomes yellowish- 
white in color and somewhat raised, and the floor of the ulcer 



THE CORNEA. 175 

seems deeper in its neighborhood. Immediately around the 
ulcer the cornea is slightly opaque, but further out it is quite 
normal. 

The degree of pain and irritation varies much, being almost 
absent in some cases, while in others it is extremely intense. 
Iritis is apt to come on at an early period, and may pass into 
iridocyclitis. Hypopyon is almost ahva}-s present. The ulcer 
creeps over the surface of the cornea in the direction of the 
curved and intensely infiltrated margin. At a still later stage 
the whole cornea is apt to become infiltrated, and the entire 
margin of the ulcer to extend, and the anterior chamber be- 
comes quite full of pus. Perforation now takes place, or may 
do so somewhat earlier. If the perforation be small, an ad- 
herent leukoma results, but if large, a staphyloma is produced. 

Causes. — Ulcus serpens always has its origin in a superficial 
corneal abscess (zddc p. 186), caused in its turn by a trauma, 
which has produced, it may be, only a slight abrasion of the 
epithelium. In a large percentage of the cases chronic dacryo- 
cystitis is present, and a considerable proportion of them oc- 
cur in the agricultural population, especially in harv^est-time. 
The investigations of Leber "^ and others make it probable that 
a fungus (aspergillus), obtaining entrance through the loss of 
epithelium, sets up the abscess which results in this peculiar 
ulcerative process. This fungus is probably present in the 
abnormal secretion of the lacrimal sac, or floats in the air dur- 
ing the oats, barley, and wheat harvest. 

Prognosis. — From the above description it will be seen that 
the process is a very severe one in many instances, and the 
prognosis bad ; }-et some cases do recover useful, although 
damaged, sight under careful treatment if it has been resorted 
to in time. 

Treatment. — If the case be not severe, atropin, with protec- 

■^ Von Graefe' s Archiv, xxv, pt. ii, p. 285. 



1/6 DISEASES OF THE EYE. 

tion of the eye, may cure in a few days. Here, too, some sur- 
geons prescribe eserin, and I am opposed to its use (p. 131). 
Warm fomentations are useful, and a pressure bandage, pro- 
vided there be no dacryocystitis. Antiseptic measures should 
always be employed, iodoform being the application most 
likely to prove of use. It may be employed either in the form 
of a strong ointment (gr. xxx ad oj) put into the eye, or it may 
be dusted on the floor of the ulcer with a camel's-hair pencil. 
Scraping the floor of the ulcer with a sharp spoon has also 
been suggested. But it is in all respects wiser to deal with 
these cases, even the apparently mild ones, actively in the 
very commencement by means of one or other, preferably the 
second, of the two following methods : 

Saemisch's method consists in division of the ulcer with a 
Graefe's cataract knife, Cocain having been applied, the 
point of the instrument is entered about two mm. from the 
margin of the ulcer, in the healthy corneal tissue, and, having 
been passed through the anterior chamber behind the ulcer, 
the counter-puncture is made in the healthy cornea some two 
mm. from the opposite margin of the ulcer. The edge of the 
knife being then turned forward, the section is slowly com- 
pleted. The incision should divide the intensely infiltrated 
part of the margin in halves. The aqueous humor and hypo- 
pyon are evacuated, atropin is instilled, a bandage is applied, 
and the patient soon gets relief from pain. Every day, until 
healing of the ulcer is well established, the wound must be 
opened up from end to end with the point of a fine probe or 
spatula, the contents of the anterior chamber being thoroughly 
evacuated on each occasion, and atropin instilled. The result 
is that, in a vast majority of cases, the progress of the ulcer is 
arrested, and healing soon sets in. The little operation should 
not be delayed long, but it may be emplo}'ed with advantage 
even in late stages of the process. 

But the actual cautery is the most valuable method of treat- 



THE CORNEA. 177 

ment for this ulcer. The infiltrated and undermined margin 
of the ulcer is the part which should be most thoroughly cau- 
terized ; but its floor, if much infiltrated, is also to be dealt 
with. The application of fluorescin just before the use of the 
cautery is of much value, as it enables the operator to clearly 
discern the whole of the diseased part requiring cauterization. 

It will not be out of place to describe here a method of treat- 
ment which has been introduced by Darier * for many affec- 
tions of the eye, but chiefly for infective ulcers of the cornea, 
and which has given very satisfactory results, not only in his 
hands, but also in the hands of others, although it has its op- 
ponents. This method consists in subconjunctival injections 
of corrosive sublimate. One-twentieth of a milligram (0.00005 
gm.) is injected under the conjunctiva at a distance of about 
one cm. from the corneal margin. As it is a rather painful 
procedure cocain must be first instilled. Some edema of the 
conjunctiva and swelling of the lids may be present on the 
following day, but it soon subsides. The only complication 
which ever occurs is a shght scar in the conjunctiva. . It is 
well to use an " iridized platinum" needle on the hypoder- 
mic syringe, as it can be sterilized each time by passing it 
through a flame. The injections may be repeated every third 
or fourth day, according to the amount of reaction.! 

Rodent Ulcer. — This is a rare and extremely dangerous 
form of ulcer. It appears as a small — sometimes even pin- 
head — gray infiltration near the corneal margin, not differing 
in appearance from many a harmless infiltration. This rapidly 
ulcerates. Other similar infiltrations appear in the neighbor- 
hood, and at other parts of the margin, and ulcerate. The 

^ AfiJial d' Oculist, 1893, t. cix, p. 241 ; ibid., t. ex, p. 145 (resume of various 
opinions) ; also Gepner, Centralblatt, f. p}-ak. AugenheiIk.,]a.n\xa.Yy, 1894. 

f The other affections in which this treatment has been of service are injuries 
of the eyeball (to prevent infection), keratitis diffusa, iritis, choroido-retinitis, 
and scleritis. 
15 



178 DISEASES OF THE EYE. 

ulcers do not go deeper than about one-third of the thickness 
of the cornea. They never penetrate. Before long they be- 
gin to heal, but leave an intense cicatrix behind. After a 
time more such ulcers form inside the position occupied by 
the first eruption, and these also heal, leaving further opacity. 
This process goes on until, finally, the whole surface of the 
cornea has been eaten away, its center being the last place 
affected, and then loss of sight is complete. The disease usu- 
ally comes on in both eyes, although there may be an interval 
between the onset in each. It attacks decrepit people of over 
middle life. The progress of the disease is very slow, as 
many weeks, or even some months, may elapse before the 
surface of the whole cornea has been destroyed. 

Treatment. — Some of these cases are amenable to the actual 
cautery, and then its use wall arrest the disease and save the 
eye. But I have seen cases in which this, and every other con- 
ceivable treatment, was tried in vain, and where both eyes were 
irretrievably lost. 

Marginal ring ulcer is a rare form, which commences as a 
clean-cut, or but slightly infiltrated, yet rather deep, ulcer at 
the corneal margin. Its tendency is to extend along the margin 
of the cornea, and in some instances healing takes place in 
the older parts of the ulcer while it is still progressive at the 
newer parts. It may extend all round the cornea, and finally 
give rise to complete sloughing of the latter by cutting off its 
nutrition. This ulcer may result in children from a marginal 
phlyctenular infiltration (p. 155), but is more common in adults, 
or in aged people whose nutrition has fallen very low. 

Treatment. — The actual cautery. Paracentesis through the 
ulcer, eserin having been first instilled. Insufflation of iodo- 
form. Warm fomentations. A bandage. Quinin, iron, and 
strychnin internally, with nutritious diet. 

Absorption ulcer (Facetted Ulcer, Superficial Transparent 
Ulcer) is the term applied to a certain definite superficial 



THE CORNEA. 179 

ulceration, which is accompanied by but Httle opacity and by 
no vascularization, and which is usually seated at or near the 
center of the cornea, where it presents the appearance of a 
shallow pit about two mm. broad, with rounded margin. If the 
eye be exposed to cold wind or other irritation, some circum- 
corneal injection makes its appearance, and the eye waters ; but 
these symptoms soon pass off again. The portions destroyed 
by the ulcerative process come away in the course of a few 
weeks, the surface begins to be covered with new epithelium, 
and reparation of the corneal tissue commences. It takes 
months for this healing process to be completed, and often 
the defect is never quite filled up, but a small facet is left, 
which is liable to interfere with vision. 

The absorption ulcer does not tend to perforate, nor to 
spread over the surface of the cornea. 

It occurs chiefly in childhood, and probably indicates mal- 
nutrition of the general system ; some observers, indeed, think 
there is a close relationship between it and phlyctenular 
ophthalmia. It is also seen in granular ophthalmia, with and 
without pannus. 

Treatment consists in atropin and protection in the early 
stages, and the yellow oxid ointment when the epithelium 
has become restored. 

Neuro-paralytic Keratitis. — In paralysis of the ophthalmic 
division of the fifth nerve purulent infiltration and ulceration 
of the cornea is often observed. It was formerly believed that 
the fifth nerve had an influence over the nutrition of the cornea, 
and hence that this was a trophic process ; but experiment has 
shown that this is not the case, and that the affection is merely 
due to the loss of sensation, which renders it possible for 
foreign substances to remain on the cornea unremoved by a 
reflex motion of the lid. This disease, therefore, cannot be 
regarded as of neuropathic origin in the strict sense of the 
term. 



i8o DISEASES OF THE EYE. 

Treatment consists chiefly in protection of the cornea by a 
bandage on the eye, or by keeping the hds fastened together 
with a dermic suture. 

Infantile ulceration of the cornea, with xerosis of the 
conjunctiva, first described by von Graefe,* is a very rare 
affection, of which a few cases came under my care at von 
Graefe' s clinic. It attacks some wretchedly delicate maras- 
matic children early in the first year of life, making its appear- 
ance at or near the centre of the cornea. Iritis always 
supervenes in severe cases. That portion of the bulbar con- 
junctiva which is exposed in the palpebral aperture at either 
side of the cornea undergoes slight epithelial xerosis, as in 
functional night-blindness due to retinal exhaustion (see Chap, 
xvii). Sometimes the xerosis of the conjunctiva is absent. f 
Ulceration of the cornea soon comes on, through necrosis of 
the layers lying over an interstitial infiltration ; and this 
ulceration spreads until it involves the whole of the cornea, 
except a very narrow^ margin. Finally, perforation, with pro- 
lapse of the iris, and panophthalmitis may supervene. 

Both eyes become affected as a rule, although the disease 
usually attacks one eye some time before its fellow. The 
patients almost always die of diarrhea, pneumonia, etc. 

Cause. — Streptococci have been found % in the corneal ulcer 
and in the conjunctiva, while a general invasion of the vascular 
system of the whole body is also present. To the latter cir- 
cumstance are referred the symptoms w^hich lead to a fatal 
termination. 

Treatment is, unfortunately, of very little avail ; but warm 
fomentations, and the use of non-irritating antiseptic lotions, 
etc., are indicated, along with an antiseptic bandage. Such 



* A. V. Graefe' s Archiv, xii, pt. ii, p. 250. 

I Holmes Spicer, Trans. Ophth. Soc. Un. K. , Vol. xiii, p. 45. 

X Leber and Wagenmann, A. v. Graefe' s Archiv, xxxiv, iv, p. 250. 



THE CORNEA. i8i 

means as may promote improvement of the general system 
will, of course, be employed. 

Herpes Corneae. — Not only in herpes zoster ophthalmicus, 
but also in herpes febrilis (or catarrhalis) is a vesicular erup- 
tion liable to occur on the cornea. According to Horner, 
herpes corneae febrilis is a rather common affection, and, he 
believed, is often not recognized by ophthalmologists because 
it usually first comes under their notice when the secondary 
ulcers have formed. The following is Professor Horner's de- 
scription of the disease : 

On the surface of the cornea of one eye is formed a group 
of clear vesicles, each from 0.5 to i.o mm. in diameter, their 
appearance being accompanied by much lacrimation, but with- 
out any swelling of the eyeHd. They usually form in a line 
which runs obliquely across the cornea, or sometimes in a 
vertical direction. Now and then they are arranged in trefoil 
shape or in a circle. The covering of the vesicles is short- 
lived, and, as already remarked, the resulting ulcer is that 
which the surgeon usually first sees. Even it, however, is 
thoroughly characteristic. On the surface of the clear cornea 
is an irregular loss of epithelium, along the margins of which 
may still sometimes be seen the shreds of the late covering of 
the vesicle. The margin of the region which is bared of its 
epithelium is dentated, and can only be mistaken for a trau- 
matic loss of epithelium. The latter, however, would never 
present the peculiar " string-of-beads " appearance. The floor 
of the loss of substance is formed by the superficial la}'ers of 
the cornea, and the anesthesia of the cornea is confined to this 
place, and does not, as in herpes zoster, extend to the rest of 
the cornea. The tension of the eye is generally reduced. 
Under favorable circumstances this loss of epithelium may be 
rapidly repaired ; although even then more slowly than one 
of equal dimensions, but of traumatic origin. Usually the 



i82 DISEASES OF THE EYE. 

healing process is slow ; and sometimes more or less intense 
opacities form in the area and at the margin of the ulcer, with 
hypopyon, iritis, etc., and the loss of substance becomes deep, 
with a dentated margin. This more unfavorable course is the 
result of secondary infection of the ulcer. 

The subjective sensations are those of a foreign body in the 
eye, with lacrimation and photophobia, and are relieved imme- 
diately after the bursting of the vesicles. 

The vesicular eruption is often regarded as irritation from 
a foreign body merely ; or, occurring in the course of a serious 
disease (pneumonia, typhoid fever, intermittent fever, etc.), it 
passes wholly unnoticed, and its relationship to the latter re- 
mains unrecognized. 

The only affection for which herpes corneae is likely to 
be mistaken is phlyctenular keratitis ; but the clear elevated 
vesicles will readily be distinguished from the flatter grayish 
mass of cells which form the phlyctene. In herpes there is 
never — although often in phlyctenular keratitis — a vasculari- 
zation of the cornea. The shape of the loss of epithelium 
after bursting of a herpes vesicle is characteristic. Phlyc- 
tenular keratitis is a disease of childhood, while herpes corneae 
is rare under puberty. 

The derangements of the system in which herpes corneae 
febrilis occurs are naturally those in which herpes febrilis 
labii, nasi, etc., are found. These are, more especially, the 
inflammatory affections of the respiratory tract, from an acute 
catarrh of the Schneiderian mucous membrane to a severe 
pneumonia. On two occasions, with an interval of three 
years, Professor Horner saw herpes corneae occur in the course 
of an attack of pneumonia in a boy. In just such cases 
herpes on the lips, ala nasi, external ear, and eyelid of the 
same side are found, and in a case of double pneumonia in an 
adult occurred the only binocular herpes corneae which Pro- 



THE CORNEA. 183 

fessor Homer had seen. He explicitly states that he had 

seen herpes cornese in connection \vith whooping-cough, and 

often with intermittent and typhoid fevers. 

But primary herpes corneae — i. c, unconnected with any 

o'ther disease — is occasionally met with, and some patients 

are liable to recurrent attacks of it. It is accompanied by 

severe neuralgia in the frontal and temporal regions, and pain 

on pressure of the supraorbital notch may be present. There 

is much lacrimation. The upper lid is red and swollen. 

The bulbar conjunctiva, especially around the cornea, is much 

infected, and there may be a few vesicles on it. Over the 

surface of the cornea, but sometimes confined to some one 

district of it, there are a number of minute vesicles, some 

shreds of epidermis — the remains of ruptured vesicles — and 

round grayish-white superficial infiltrations not larger than a 

pin's head. The mucous membrane of the nostrils is also apt 

to be attacked, causing- swelling; of it, with much secretion, 
'00' ' 

and the formation of scabs. 

Treatment at an early stage, before the vesicles have burst 
or the loss of substance has become infiltrated, consists in 
protection of the eye, and, when infiltration has set in, in dis- 
infection with protection. If the vesicles give great pain they 
may be ruptured by dusting a little calomel into the eye, or 
by brushing it with a camel' s-hair pencil w^et with solution 
of boracic acid, after which a well-fitting antiseptic bandage is 
applied. Cocain is valuable in these cases, for relief of the 
pain. Atropin and warm fomentations should also be em- 
ployed, and a w^eak yellow oxid ointment is of use in some 
cases. Where the nostrils are afifected, weak sublimate or 
other antiseptic washes should be appHed to the Schneiderian 
mucous membrane. 

Filamentous Keratitis (Fadchen-Keratitis). — Of this form 
of keratitis I have as yet seen but one case. It may occur 
with or without superficial injury to the cornea. Its name is 



i84 DISEASES OF THE EYE. 

due to the fine threads, Hke twisted spun-glass, several of which 
hang from the surface of the cornea, and give the condition 
its characteristic appearance. These threads never reach a 
length of more than three or four mm. 

Different views are held as to the mode of origin of the 
threads. Fischer and Uhthoff* have observed that small 
vesicles, with clear or turbid contents, appear in groups upon 
part of the cornea, then burst, and from the center of each 
resulting depression a thread hangs out. The onset of the 
vesicles is accompanied by much pain and photophobia, and 
probably has its cause in some affection of the fifth nerve. 
The duration of an attack is usually short, but there may 
be several relapses at brief intervals, and finally the process 
ceases without permanent damage to the cornea. These same 
authors hold that the threads are composed of the peculiar 
fibrinous contents of the vesicles. But it has been proved 
now beyond doubt by the investigations of Hess f and Nuel J 
that the threads are composed of twisted, proliferating epi- 
thelial cells, each thread ending in a bulbous enlargement 
caused by degeneration of the epithelium. A peculiar 
diseased condition of the corneal epithelium precedes the 
formation of the vesicles and threads. Leber now admits the 
epithelial origin of the filaments, although he originally be- 
lieved them to be fibrinous products. 

Treatment. — Protection of the eye with a bandage. Atro- 
pin. Yellow^ oxid of mercury ointment put into the eye. 
Warm fomentations. 

Bullous Keratitis. — Bullae very rarely form on the cornea. 
They are seldom the primary condition, but usually depend 
on an interstitial diseased process in the cornea. This process 



*"Berichtd. Ophthal. Gesellsch.," 1889. 

■\ A. von Graefe's Archiv, xxxviii, part i,p. 160 ; ibid., xxxix, part ii, p. 199. 

X Arc/iiv d' Ophthalmologie, xiii, iv, p. 193. 



THE CORNEA. 185 

may itself be a primary disease ; but more commonly it, too, 
is secondary to deep changes in the eye, such as absolute 
glaucoma, iridocyclitis, etc. I have a few times seen bullae 
form on the cornea of otherwise sound eyes in persons whose 
health was in a debilitated state. The formation of a bulla is 
attended by much pain and photophobia, which disappear as 
soon as the bulla ruptures. One, or more than one, bulla may 
form at a time. After a day or two they rupture, and their 
walls then hang in shreds from the surface of the cornea, and 
the seats of the bullae present shallow depressions. These 
losses of substance heal without leaving any permanent opacity. 
After an interval of days or weeks another crop of bullae ap- 
pears, and runs the same course. 

Treatment. — The bullae should be opened, and their walls 
snipped away with scissors, and a bandage applied. The 
recurrent attacks may cease after a length of time, but so far 
as treatment can influence them it can only be done by reliev- 
ing the process in the cornea which gives rise to them. If it 
be a primary process, warm fomentations, atropin, and a band- 
age, with remedies directed to correction of any fault in the 
general state of the health which may exist, are suitable ; or 
if, as is more common, a deep ocular process (glaucoma, etc.) 
be the cause, the recognized treatment for this latter must be 
adopted. 

Dendriform (di^Spov, a tree) Keratitis. — This is a rare af- 
fection, to which attention was first drawn by Hansen Grut, of 
Copenhagen. It is a very superficial and chronic ulceration, 
with but little infiltration of its margins or floor, and present- 
ing the appearance of a fine groove on the cornea. It spreads 
chiefly over the central region of the cornea by throwing out 
branches on either side. The pain and irritation are sometimes 
severe, and again but slight or quite wanting. Some perma- 
nent opacity often remains when cure has been effected. 

The cause has not been definitely ascertained, but the pecu- 
16 



i86 DISEASES OF THE EYE. 

liar progress of the affection renders it almost certain that 
some special fungus is engaged. 

Treatment. — Scraping with a sharp spoon, with the subse- 
quent application of i : looo solution of corrosive sublimate 
to the cornea, is recommended by some, and the actual cautery 
is of great use. But I can strongly recommend the application 
of absolute alcohol, which, I find, affords a certain and rapid 
cure. I soak a bit of lint in the alcohol and scrub the sur- 
face of the cornea with it. This may require to be repeated 
once or twice, at intervals of a day or two. 

(p) NON-ULCERATIVE INFLAMMATIONS OF THE CORNEA. 

Abscess. — This affection is on the borderland between the 
ulcerative and non-ulcerative inflammations of the cornea, 
for in one case it will result in an ulcer — usually the ulcus 
serpens — while again it will run its course without ulceration. 
The abscesses which are seated in the more superficial layers 
are those which go on to ulceration ; those in the deeper 
layers are less likely to do so. 

Abscess differs from infiltration in that the pus which forms 
it destroys the true corneal tissue — the fibrillse and fixed cor- 
puscles — and does not merely lie between them. 

Signs and Symptoms. — The appearance presented is that of 
a yellowish, circumscribed opacity, more intense at its margin 
than at its center, seated at or near the middle of the cornea, 
and surrounded by a light gray zone. It is usually round in 
shape, but when situated near the edge of the cornea it is apt 
to be crescentic. The surface of the cornea just over the 
abscess is at first a little elevated over the general surface, but 
later on becomes flattened, owing to a falling-in of the normal 
layers anterior to the abscess ; and the epithelium of the flat- 
tened part has a dull, breathed-on look. The rest of the 
cornea may also lose its brilliancy, although in a much less 
degree. Hypopyon and iritis are constant attendants upon 
corneal abscess. There is much injection of the conjunctival 



THE CORNEA. 187 

and ciliary blood-vessels. Severe pain in and about the eye 
and blepharospasm are common. Occasionally a corneal ab- 
scess will be attended by but little pain or other irritation. 

Progress. — The abscess spreads through the cornea, usually 
in some one direction, and this direction is indicated by the 
yellowish opacity being more intense at the advancing side 
of the abscess. Before long, if the abscess be superficial, the 
layers of cornea covering it come away, and the condition is 
changed into that of the ulcus serpens, already described. The 
deeper abscesses spread through the cornea more or less 
widely, and ultimately become absorbed, without having 
caused ulceration. But even these abscesses leave consider- 
able opacity behind. Of the two, the process which ends in 
ulceration is the more common. 

Etiology. — Abscess is the result of infection of the cornea 
with pyogenic organisms, which reach it either from without, 
through some traumatic loss of substance of the corneal 
epithelium, or from within, by the agency of the blood. The 
microorganisms, which are introduced through a superficial 
loss of substance, may either have been on the foreign body 
which produced the injury, or they may have been present in 
the conjunctival sac. Infection through the blood is occa- 
sionally seen in some acute exanthematous diseases, such as 
scarlatina, measles, and small-pox ; more especially in the 
latter in its convalescent stage. 

Treatment. — Atropin, warm fomentations, and a bandage. 
But if these mild measures do not, in a day or so, arrest the 
progress of the abscess, resort must be had to the actual 
cautery. 

Diffuse Interstitial, or Parenchymatous, Keratitis. — 
This affection occurs most commonly between the ages of five 
and fifteen. It usually commences at some one part of the 
margin as a light grayish opacity, accompanied by slight injec- 
tion of the ciliary vessels. The rest of the corneal margin 



l88 DISEASES OF THE EYE. 

soon becomes similarly affected ; and then, gradually, the 
opacity extends concentrically into the cornea, or does so by 
sending in processes which afterward become confluent. In 
this way the whole cornea becomes affected by degrees, and 
its epithelium acquires the breathed-on or ground-glass appear- 
ance, which is seen, also, in acute glaucoma. The opacity 
lies in the deep layers of the true cornea, and is slightly more 
intense in spots here and there. It is sometimes only a very 
light cloud, while again the cornea may be so opaque as to 
render the iris quite invisible. When the whole cornea has 
become opaque, it begins to clear up at the margin, and the 
central portion becomes even more opaque than the margin 
had ever been, a fact which shows that the very cells which 
entered the cornea at it margin have advanced to its center. 
The clear margin gradually increases in width until only a 
rather intense central opacity is left. This central opacity 
slowly breaks up and becomes absorbed, but not always com- 
pletely, and then considerable and permanent impairment of 
vision may remain. Occasionally the opacity commences at 
the center of the cornea and extends toward the margin, 
which it often does not reach before clearing commences. 

New vessels form in the cornea in its posterior layers, but 
the degree of vascularization varies greatly in different cases. 
In some cases the presence of vessels can only be ascertained 
by careful examination with a magnifying glass or the corneal 
microscope ; while in others the new vessels are present in 
great numbers, and can be readily seen with the naked eye. 
In other cases, again, close leashes of vessels follow the tongues 
of opacity into the cornea, giving rise to the appearance known 
as the " salmon patch." 

In severe cases iritis and choroiditis are nearly always pres- 
ent, although the latter is not observable until the cornea has 
become clear enough to admit of an ophthalmoscopic exami- 
nation. The disease, indeed, must be regarded, strictly speak- 



THE CORNEA. 189 

ing, as one of the uveal tract, to which the posterior layers of 
the cornea, which are mainly diseased, belong. 

The two forms above described, one commencing at the 
margin, the other at the center of the cornea, and more or less 
vascularized, but for the most part ultimately occupying the 
entire cornea, are those we are wont to find in children and 
young adults, and which, as will just now be stated, have con- 
genital syphilis as their usual cause. But in older persons, up 
to thirty or thirty-five, interstitial keratitides of milder forms 
are met with. These rarely occupy more than a small region 
of the cornea, either as a patch or as a ring of opacity, and 
with little or no vascularization. 

The affection is often accompanied by a good deal of pain 
and blepharospasm, especially in the severe vascular forms, 
and there, too, the tension of the eye is apt to be temporarily 
reduced. 

The acute stage of the disease lasts from six to eight weeks, 
or longer. But the entire process may not be completed for 
many months, and in one case which I saw the opacity did 
not begin to clear away for eleven months after the cornea was 
first attacked, the whole process extending over a period of 
two years. 

Both eyes invariably become affected, although not always 
at the same time, the second eye being often not attacked until 
the inflammation in the first has made some progress, or, per- 
haps, not until it has undergone cure. It is important to ac- 
quaint the patient or his parents with the likelihood of this 
course of events in the very commencement of his treatment. 

In adults usually one eye alone is attacked ; iritis is rare, 
the duration of the process is comparatively short, and the 
complete clearing up is relatively frequent. 

Causes. — The affection is more common in girls than in 
boys, and most frequently appears during second dentition, 
when the upper incisors are being cut, or at puberty. It de- 



I90 DISEASES OF THE EYE. 

pends upon some serious derangement of the general nutri- 
tion ; and this, in over 50 per cent, of the cases, is inherited 
syphihs, a fact which was first pointed out by Mr. Jonathan 
Hutchinson. The children are generally thin, anemic, and of 
stunted growth, with flat nose, cicatrices at the angles of the 
mouth, often more or less deaf; and the peculiarities of the 
incisor teeth, so well known from Mr. Hutchinson's descrip- 
tion, are present in about one-half of the cases. 

Occurring in adults, the affection is rarely due to inherited 
syphilis, although acquired lues may sometimes be taken as 
its cause ; while, again, it will often be impossible to assign 
any origin for it other than the universal one of exposure to 
cold, etc. Von Hippel * is of opinion that some cases are due 
to tubercular disease. He found microscopic appearances, 
very suggestive of tubercle, in the iris and deeper parts, in an 
eye with interstitial keratitis. 

Prognosis. — In children, — in view of the possibility of an 
incomplete clearing of the cornea, and the irregularity of its 
surface which the process may cause, as well as of the serious 
complications liable to supervene, and which may completely 
annihilate vision — the prognosis must be guarded (although by 
no means hopeless) in those cases where the opacity is very 
intense, or where there is much vascularity. Yet in the milder 
cases a very favorable prognosis may be given. I have never 
seen the affection recur, but it is said to do so veiy rarely. 

In adults, as stated, the prognosis is much more favorable. 

Treatment. — In the early stages no irritants should be 
locally applied. Atropin is important for the prevention of 
iritis or of posterior synechia ; and the use of warm moisture, 
in the form of poultices or fomentations, promotes vascu- 
larization, and hastens absorption of the cellular elements 
which form the opacity. When the acute stage is ended, the 

* Centralbl. f. Augenheilk., June, 1893, p. 174. 



THE CORNEA. 191 

yellow oxid ointment may be employed with benefit for 
stimulating the absorbents to carr}' off the remains of the 
opacity. Massage may be used with advantage in both stages 
to disperse the infiltration. In severe cases I would advise a 
course of mercurial inunctions, continued for several weeks, 
care being taken not to allow stomatitis to exceed very mod- 
erate bounds. In mild cases a tonic plan of treatment, with 
iodid of iron and cod-liver oil, is the most suitable. 

In adults, where it is desirable to use mercurial treatment, 
a good method is the hypodermic injection of perchlorid 
of mercury (^q- to 2V g^O once a day. From this I have had 
satisfactory results, but mercurial inunctions also answer well 
and are less painful. 

Counterirritation, in the form of blisters to the temple or 
a seton to the scalp, is extensively employed by some surgeons. 
I have never adopted this treatment, as I doubt its value, 
and am loath to add a worry to the troubles inseparable from 
so wearisome a disease. 

Keratitis Punctata. — This term is commonly given to 
a condition which occurs in cyclitis, in iridocyclitis, and in 
sympathetic ophthalmitis (Chap, x), and which is never a 
primary disease of the cornea. The condition should, strictly 
speaking, be considered only under those headings, but, as 
the beginner will naturally look for the description of a 
diseased state bearing such a name in the chapter on Diseases 
of the Cornea, I include it here. 

It is due to the deposit of minute beads of h-mph on the 
membrane of Descemet, which gives to the affected part of 
the cornea a finely-dotted appearance. The lymph is usually 
found only on the lower quadrant of the cornea — ^because it 
gravitates to the lowest part of the anterior chamber — in a 
triangular space, of which the base is at the corneal margin, 
while its apex is directed toward the center of the cornea. 
This triangular shape is the result of the motions of the eye- 



192 DISEASES OF THE EYE. 

ball, which throw the lymph beads against the cornea. In 
some cases the spots are scattered irregularly over the whole 
surface of the posterior elastic lamina. 

When the process which gives rise to this condition passes 
off rapidly the cornea is restored to its normal state. But 
when the primary disease is chronic, the nutrition of the true 
cornea, in the triangular space corresponding to the deposit 
of lymph, is apt to be interfered with — by reason of degenera- 
tion of the endothelium of Descemet's membrane, which 
protects the cornea from the aqueous humor — so that it be- 
comes intensely and permanently opaque. 

Fuchs * has described a form of keratitis which he terms 
keratitis punctata siLperficialis, and which has a good claim to 
that name. It begins with the symptoms of an acute con- 
junctivitis. Either at the same time, or some days or weeks 
afterward, minute gray spots may be seen in the superficial 
layers of the cornea, the epithelium over the spots being 
somewhat raised up. The spots are often arranged in groups 
or rows, and may be scattered over nearly the entire cornea, 
or else confined to its central region. There may be alto- 
gether only a very few of them, or there may be a hundred 
or more, and one or both eyes may be affected. The initial 
irritative symptoms soon disappear, but the spots themselves 
remain for many weeks, or longer, and finally fade away en- 
tirely. It is more common in young people than in later life, 
and most usually in connection with a catarrh of the air pas- 
sages. The spots are often very faint, and hence can easily 
be overlooked unless searched for with the oblique hght. In 
this country the affection is rather rare, but we have had sev- 
eral cases of it at the National Eye and Ear Infirmary. 

TJie treatment should consist in atropin, bandage, and warm 
fomentations. 

* " Handbuch der Ophthalmologic." 



THE CORNEA. 193 

Sclerotizing opacity of the cornea sometimes complicates 
scleritis, affecting the cornea in the neighborhood of the 
scleral affection, but not extending more than two to three 
mm. into the cornea, except in very severe cases. It is an 
intense white opacity situated in the true cornea, and is apt 
to remain as a permanent opacity, even when the scleritis 
undergoes cure. In such cases of sclero-keratitis iritis is 
often present. 

Treatincnt. — Warm fomentations, massage, and the treat- 
ment of whatever diathesis (rheumatism, syphilis) may be 
taken as gi\'ing rise to the scleritis. 

Ribbon-like Keratitis (Transverse Calcareous Film of the 
Cornea ; Calcareous Film of the Cornea). — This is an altera- 
tion which occurs chiefly in the cornccE of eyes destroyed 
by severe intraocular processes, such as iridocyclitis, sympa- 
thetic ophthalmitis, glaucoma, etc. It occupies that transverse 
strip of the cornea which is uncovered in the commissure of 
the eyelids during waking. It usually commences on the in- 
ner margin of the cornea, but soon appears at the outer mar- 
gin, and advances from each direction toward the center, where 
the two sections join. It presents the appearance of a grayish- 
brow^n opacity with, in many, but not in all cases, white cal- 
careous deposits in and under the epithelium. Magnus* points 
out that in blind eyes which are constantly rolled upward the 
opacity is found, not in the central transverse section of the 
cornea, but in its lower third, and from this circumstance he 
argues that the chief factor for its production is exposure of 
the part affected. He believes, moreover, that so large a pro- 
portion of the affected eyes having suffered severely in their 
general nutrition indicates that the opacity is a further devel- 
opment of this malnutrition. He proposes for the affection 
the name keratitis trophica. 

"^ Klin. Monatsbl. f. Angenheilkunde, February, 1883, p. 45. 



[94 



DISEASES OF THE EYE. 



ECTASIES OF THE CoRNEA. 

Staphyloma cornese is the result of a perforating ulcer of 
the cornea. This, having healed, may present a weak cica- 
trix, which becomes bulged forward by even the normal in- 
traocular tension (Figs. 57 and 58). If the iris be not in- 
volved in this cicatrix, the anterior chamber will be made 
deeper (Fig. 58). 

Staphyloma corneae in which the iris is involved is probably 
a more common condition than the above. 

When the ulcer is large, a correspondingly large portion of 
iris is liable to become prolapsed into it, and to form a bulging 





Fig. 57. — [Page nstec her.) 



Fig. 58. — ( Pagenstecher. ) 



mass outside the eye. This may burst and collapse, and a flat 
cicatrix may be formed ; or, if it does not rupture, it may form 
what is termed a partial staphyloma of the cornea and iris, 
the latter becoming consolidated by the formation of a layer 
of connective tissue over it. 

If the whole, or a very large part, of the cornea be destroyed 
by an ulcer, the iris is completely exposed. It soon begins to 
be covered with a layer of lymph, which develops into an 
opaque cicatricial membrane. Should this not be strong, the 
normal intraocular tension is sufficient after a time to make it 
bulge ; or increased intraocular tension may arise in conse- 
quence of further changes within the eye, and then bulging 



THE CORNEA. 195 

of the pseudocornea more surely comes on, and the condition 
is termed total staphyloma of the cornea. Sometimes a total 
staphyloma has a lobulated appearance, owing to the pseudo- 
cornea having some fibers stronger than others, and hence the 
name given to the condition, from aracpuXri^ a biincli of grapes. 
Such staphylomata are apt to gradually increase to a very large 
size. 

Treatment. — In cases of partial staphyloma where a clear 
portion of the cornea remains, an iridectomy is frequently in- 
dicated for the reduction of the tension — so that further bulging 
may be arrested — as well as for the sake of the artificial pupil, 
which may improve sight in cases where the normal pupil is 
obliterated by corneal opacity. When, sight having been lost, 
the staphyloma is very bulging, or w^hen total staphyloma is 
present, enucleation of the eyeball or one of the following 
operative measures must be adopted : 

Abscision. — A Beer's cataract knife being passed through 
the base of the staphyloma, with its edge directed upw^ard, 
the upper two-thirds of the staphyloma are separated off, w^hile 
the remaining third is detached by means of scissors. If 
the lens be present it must now be removed. The wide open- 
ing becomes filled up with granulations, and cicatrizes over. 

In de Wecker's * method the opening is closed with con- 
junctival sutures. He begins the operation by separating the 
conjunctiva all around the margin of the cornea, and by then 
loosening it from the eyeball nearly as far back as its equator. 
Four sutures {a, b, c, d) of different colors are then passed 
through the conjunctiva about two to three mm. from the mar- 
gin of the wound, as represented in figure 59. In order to keep 
the field of operation clear, the ends of two of these sutures 
are laid over on the nose, w^hile the others are laid over on the 
temple. The staphyloma is now abscised, and the sutures 

* " Chirurgie Oculaire," p. 188. 



196 



DISEASES OF THE EYE. 



drawn together and tied. The conjunctival scar, de Wecker 
states, can be tattooed in the center at a later period, and by 
this means the wearing of an artificial eye made unnecessary. 
De Wecker has also recommended repeated puncturing of the 
sclerotic behind the ciliary region for the purpose of diminish- 
ing the size of the globe. 

The foregoing, and other methods of abscision, are only 
applicable where the tension is either low or normal. If it 
be high, the liability to intraocular hemorrhage during the 
operation makes enucleation, evisceration, or Mules' operation 




Fig. 59. 

more suitable proceedings. Indeed I, and probably most 
surgeons, would now employ one of the two latter operations 
in all these cases. 

Evisceration was proposed about the same time by Professor 
Graefe, of Halle,* to prevent death from meningitis after the 
removal of suppurating globes, and by Mr. Mules, f of Man- 
chester, chiefly to take the place of enucleation in cases of 



Centralbl. f. Augenheilk., 1884, p. 378. 



"[ Ibid., 1885, p. 32. 



THE CORNEA. 197 

sympathetic ophthalmitis. There are some who are opposed 
to its employment in those cases, but for staphyloma of the 
cornea it cannot meet with any such opposition. 

The cornea is removed by making an incision with a 
Graefe's knife so as to include one-half of the corneo-scleral 
margin, and completing the circumcision with scissors. All 
the contents of the globe are then evacuated by means of ]\Ir. 
Mules' scoop, care being taken to remove the choroid un- 
broken by carefully peeling it from the sclerotic margin back- 
ward until it is only held at the lamina cribrosa. The scoop 
is then used to lift the separated unbroken choroid and its 
other contents out of the globe. 

Finally, the margins of the sclerotico-conjunctival wound 
are drawn together with a few points of suture. The whole 
proceeding should be done with strict antiseptic precautions, 
chief among which is the free use of irrigation, with a i : 
5000 solution of corrosive subHmate, before, during, and after 
the operation, the interior of the globe being most carefully 
washed out with the solution in a full stream. The result is 
a fairly good and freely movable stump for the application of 
an artificial eye. 

Mules Operation. — This proceeding, a modification of the 
foregoing, was also proposed by ]\Ir. Mules "^ for cases of 
threatened sympathetic ophthalmitis, and, like simple eviscera- 
tion, has not yet met with universal acceptance in those cases. 
Its object is to provide a still better stump for the artificial eye 
by the insertion into the scleral cavit}* of a hollow glass ball, 
called an artificial vitreous humor. It is performed as fol- 
lows : 

The cornea is removed, the conjuncti\-a having first been 
freed from the scleral edge toward the equator of the eye- 
ball, and the contents of the e}-eball evacuated, as in simple 

* Tratis. Ophthal. Soc, Vol. v, p. 200. 



198 DISEASES OF THE EYE. 

evisceration. The opening is now enlarged vertically, to 
admit of the introduction of one of the glass spheres. This 
introduction is best effected by means of a special instrument 
designed for the purpose by Mr. Mules. The spheres are 
made * in several sizes to suit different cases, and it is well not 
to use the largest which will fit into any given eye. The 
margins of the sclerotic opening are now united vertically by 
some points of interrupted suture, for which purpose I prefer 
silk to catgut, as the latter is apt to undergo absorption before 
complete union has taken place. The conjunctival opening is 
then closed by another set of sutures placed at right angles 
to the sclerotic line of closure. Similar antiseptic precautions 
are required as in simple evisceration, and care must be taken 
that all bleeding in the cavity has ceased before the glass 
sphere is inserted. Before the lids are closed the anterior 
surface of the globe is well covered with powdered boric acid. 
A firm antiseptic bandage is applied. I do not dress the eye 
for forty-eight hours, and subsequently once every twenty- 
four hours, using the corrosive sublimate solution freely, and 
boric acid powder. There is generally some reaction, con- 
sisting of chemosis, swelling of the eyelids, and pain ; and 
sometimes these symptoms are very marked, especially if 
rather too large a sphere has been employed. In the course 
of a week or so this all passes off, and a very perfect stump is 
obtained. 

To prevent excessive reaction, Mr. Mules burrows into the 
orbit at the outer side, so that the points of the scissors may 
penetrate well beyond the back of the globe, and then intro- 
duces deeply a drain of gold wire, such as is used by dentists, 
bringing it out between the lids at the outer canthus. An 
ice-bag is applied. The drain is left in about three days. 

The danger that the glass sphere may get broken by a blow 

* By Messrs. Armstrong, of Deansgate, Manchester. 



THE CORNEA. 



[99 



upon the eye has been put forward as an objection to this 
method. No doubt it is an accident which may occur, and 
would then necessitate the enucleation of the eye ; but no 
case of the kind has as yet been recorded, although the opera- 
tion has been in use for ten years. Silver spheres, instead 
of those of glass^ have been sometimes employed to obviate 
the danger referred to. 

I can heartily recommend this procedure. I have used it 
about fifty times, and I am much pleased with it, for the 
cosmetic result it gives is infinitely better than that pro- 
duced either by complete enucleation or by evisceration of the 
eyeball. It is, I think, more uniformly successful in young 
people than at more advanced ages, and to secure success, an 
important point, I find, is to take care that the glass globe is 
not too large. It should be an easy fit for the cavity of the 
sclerotic. In case the sutures give way and the sclerotic 
opening gapes, an attempt may be made to reclose it with 
new sutures, but I do not find this often of use. As a rule, 
the glass globe must in that event be removed, and the case 
then becomes one of simple evisceration. 

Conic Cornea, or Keratoconus. — In this the cornea is 
altered in shape to that of a cone. The change is due to a 
gradual and slowly-advancing atrophic 
process in the cornea, especially at its 
center, in consequence of which the nor- 
mal intraocular tension acts on it so as 
to distort it into the form represented in 
figure 60. Tweedy "^ has shown that yig 60 

there may be some congenital weakness 

in the center of the cornea as the result of its mode of devel- 
opment. The cornea remains clear, except sometimes just at 
the apex of the cone, where a slight nebula may be present. 

* Trans. Ophthal. Soc. Un. K., Vol. xii, p. 67. 




200 DISEASES OF THE EYE. 

The condition is easy of diagnosis in its advanced stages by 
mere inspection of the cornea, especially in profile, but in its 
commencement it may not be so. 

In the early stages, when the light is thrown on the cornea 
from the ophthalmoscopic mirror, as for retinoscopy, the 
corneal reflex will be noticed to be smaller at the center, 
owing to the greater curvature there. Moreover, a dark 
shadow, circular or crescentic in shape accordmg to the 
incidence of the light, appears between the corneal margin 
and center ; and, finally, when the fundus is examined, its 
details will be seen distorted. 

The process begins in early adult life, progresses slowly, 
never leads to rupture or ulceration of the cornea, and, 
finally, after many years, ceases to progress, but does not 
undergo cure. Both eyes are apt to become attacked, one 
after the other. The disturbance of vision is very great, 
owing to the extreme irregular astigmatism produced. 

lyeatinent. — In the early stages, or in slight cases, an 
improvement in vision may be obtained by means of concave 
spheric or sphero-cylindric glasses ; for, as is evident, 
the change in shape of the cornea must cause the eye to 
become myopic. The refraction of the central portion of the 
cornea may be ascertained by retinoscopy, with the aid of 
a stenopeic disc in the trial-frame, as recommended by 
Mackay.* At a later period these glasses are of little use. 
Hyperbolic lenses have been employed, but although they 
may raise the acuteness of vision there are obvious diffi- 
culties in the way of the practical every-day use of them. 
A stenopeic slit renders assistance in some cases. 

Glass shells, which are known as contact glasses, have been 
introduced by Fick for the temporary relief of irregular re- 
fraction. They are worn in contact with the eye, and may 

*Ophthal. Review, December, 1893, P- 3^1- 



THE CORNEA. 201 

enable some patients to work for hours at employments which 
they could not otherwise carry on. 

A few cases are reported in which the keratoconus was 
much reduced and vision greatly bettered by instillations of 
eserin, and the application of a pressure bandage, continued 
for several months. 

But it is upon operative measures we must chiefly rely in 
this affection for any improvement in sight. 

Von Graefe's method consists in flattening the cornea by 
the production of an ulcer on the apex of the cone, and the 
resulting cicatricial contraction. From the surface of the 
cornea, a little to one side of the apex of the cone, a morsel 
of corneal substance is removed with a cataract knife, care 
being taken not to open the anterior chamber. On the second 
day after this proceeding the wound is touched with mitigated 
lapis (solid), and this is repeated every third day for a fortnight 
or three weeks. Paracentesis of the anterior chamber is then 
performed through the floor of the ulcer, and the aqueous 
humor is evacuated every second day for a week, after which 
the healing process is allowed to take its course. A bandage 
must be worn during the whole course of the treatment. 
Finally, when the contraction and consequent flattening are 
completed, a narrow iridectomy may be necessary, in conse- 
quence of the central, or almost central, and rather intense 
corneal opacity. 

In Bader's method a small, elliptic flap of the cornea at 
its apex is removed, and the margins are brought together by 
one or two fine sutures. The sutures are omitted by many 
surgeons as useless, and as liable to cause irritation. Opinion 
is divided as to whether the ellipse should lie vertically or 
horizontally in the cornea. Anterior synechia takes place in a 
large number of the cases, and a subsequent optic iridectomy 
is always required. I have myself no experience of this 
operation, but it is said to be attended with unusual risk 
17 



202 DISEASES OF THE EYE. 

of suppuration of the cornea, going on to destruction of 
sight. 

Sir William Bowman's method consisted in cutting a disc 
on the apex of the cornea with a small trephine, and then 
severing this disc with forceps and cataract knife. Cicatriza- 
tion of the wound produces the desired flattening of the cone. 
Septic infection is here also a danger, although it has not 
come under my own observation. 

I have myself, in one case, employed the electro-cautery 
to produce the desired loss of substance on the apex of the 
cone, but I am not as yet in a position to speak of the ultimate 
result. I believe that others have used the electro-cautery 
with good result for sight. The proceeding is free from all 
risk of septic infection. 

With the same object some surgeons have had recourse to 
multiple puncturings of the apex of the cone with a fine 
cataract needle. The summit of the cone is transfixed from 
three to six times at each sitting, and this may be repeated 
at intervals of two weeks or more. The first effect of the 
punctures is to allow some of the aqueous humor to escape, 
and then the eye is firmly supported with a bandage. The 
pupil is kept under the influence of eserin. Eventually a 
network of cicatricial tissue forms, which flattens the cone 
without giving rise to much corneal opacity. 

Tumors of the Cornea. 
Primary tumors of the cornea are extremely rare. Epi- 
thelioma and sarcoma have their origin not in the cornea, 
but in the Hmbus conjunctivae (p. 149). Dermoid tumors 
are usually seated partly on the conjunctiv^a and partly on the 
cornea (p. 147). Yet a very few cases of papilloma, epithe- 
lioma, and fibroma are recorded as taking their origin in the 
cornea. Corneal cysts also occur. 



THE CORNEA. 203 

Injuries of the Cornea. 

Foreign bodies in the cornea, such as morsels of iron, 
stone, coal, etc., are amongst the most common accidents of 
the entire body. The pain caused by these foreign bodies is 
very considerable, as may be imagined, when the rich nervous 
supply of the cornea is remembered. 

The dangers which may follow on the presence of a foreign 
body in the cornea depend partly upon the infection or non- 
infection of the foreign body, and partly upon the depth at 
which it is buried in the cornea. The deeper a foreign body 
lies, the more difficult will be its removal, and the greater 
must be the laceration of the cornea caused by its removal. 
A foreign body which carries infection upon it will be more 
likely to set up serious inflammatory reaction than one which 
is aseptic or nearly so. For this reason it is important to 
ascertain, if possible, the origin of the foreign body, although 
an apparently aseptic origin must not set all suspicion on this 
point at rest. 

Many foreign bodies are so small as to defy detection until 
the cornea is searched with the oblique light, an aid which 
should always be made use of whenever the symptoms or 
history in the remotest way suggest the presence of a foreign 
body. 

A foreign body which lies only in the epithelium or in the 
superficial layers of the cornea is easily removed. The eye 
having been thoroughly cocainized, the patient is seated and 
leans his head against the chest of the surgeon, who stands be- 
hind him. With the index finger of the left hand the surgeon 
then lifts the upper lid of the injured eye, pressing the margin 
of the lid upward and backward, while with the second finger 
he depresses the lower lid in a similar manner, and between 
these two fingers he can, to a great extent, restrain the motions 
of the eyeball. The foreign body is now to be pricked out of 



204 DISEASES OF THE EYE. 

the cornea with a special needle, with as little injury of the 
general surface as possible, the patient all the while directing 
his gaze steadily at some given point. If the foreign body be 
deep in the layers of the cornea, it must be dug out, as it 
were, and a minute gouge is made for this purpose. 

Care must be taken not to infect the cornea in the removal 
of a foreign body, and consequently thorough antiseptic pre- 
cautions must be taken. After the foreign body is removed, 
the place where it was seated should be washed with a i : 5000 
solution of corrosive sublimate. A bandage is worn until the 
epithelium is regenerated — /. e., for several days. 

Every surgeon and general practitioner should possess the 
two small instruments required for the removal of superficial 
corneal foreign bodies, and should understand the use of them. 

The magnet is of no use whatever for the removal even of 
superficially seated foreign bodies of steel or iron in the cornea. 

Sometimes a foreign body in the cornea will be so long as 
to protrude somewhat into the anterior chamber, and there 
is danger that in the attempts at removal it may be pushed 
further on, and fall into the anterior chamber. Here it is 
necessary to pass a keratome through the cornea, and behind 
the foreign body, so as to provide a firm base against which 
to work, or the keratome may be made to push the foreign 
body forward. 

The wing-cases of small beetles and scales of seeds may 
get into the eye, and adhere to the cornea by their concave 
surface for several days. 

Simple traumatic losses of substance of the surface of 
the cornea, involving the most anterior layers of the true 
cornea, or perhaps merely the epithelium, are very common 
from rubs or scratches with branches of trees, finger-nails, 
etc., etc. These injuries heal readily by protecting the eye 
with a bandage ; but when neglected, or if septic matter have 
been introduced when the injury occurred, or if it be present 



THE CORNEA. 205 

in the conjunctiva or lacrimal sac, these losses of substance 
are capable of forming the starting-point of corneal abscess 
(p. 186), ulcus serpens (p. 174), etc. 

Opacities of the Cornea. 

Nebula, Macula, Leukoma. — These terms are applied to 
opacities of varying degrees in the cornea, which are the result 
of some diseased process, or consequent upon an injury. The 
first term is used for very slight opacities, often discoverable 
only with oblique illumination. Macula indicates a more in- 
tense opacity, recognizable by daylight. Leukoma is a com- 
pletely non-translucent and intensely white opacity, the result 
always of an ulcer which has destroyed most of the true 
corneal tissue at the affected place ; indeed, it is often the re- 
sult of an ulcer which has eaten its way through the cornea. 
In these latter cases the iris may have become adherent in the 
corneal cicatrix, and then the term leukoma adherens is 
employed. 

Very often eyes with a nebulous condition of the cornea of 
old standing are myopic. It is probable that this myopia is 
produced by the habitual close approximation of objects to 
the eye, owing to the diminished acuteness of vision from the 
opacity of the cornea. 

Treatmoit. — Little or nothing can be done to reduce these 
opacities. In slight and fresh cases, massage may render 
them less intense. 

In nebulous cornea a stenopeic apparatus often improves 
the sight. This consists of a metal plate with a small central 
hole or slit, which is placed before the patient's eye in a 
spectacle frame. By this arrangement a large portion of the 
rays which pass through irregular parts of the cornea, and 
which merely confuse the sight, is cut off Where myopia 
is present, the suitable concave glasses for distant vision 
should be prescribed. 



2o6 DISEASES OF THE EYE. 

T]ic operation of tattooing was first proposed by de Wecker, 
and is a valuable proceeding for improvement of the appear- 
ance of the eye in cases of leukoma. But it is also an 
extremely useful method for the improvement of the sight 
in certain cases of nebula of the cornea where the nebula 
occupies only part of the pupillary area of the cornea. In 
these cases much disturbance of sight is caused by the 
dispersion of the light which makes its way through the 
nebula ; and when by tattooing the scar all light is pre- 
vented from getting through, brighter and distincter vision 
is enjoyed with the part of the cornea opposite the pupil, 
which is absolutely clear. 

In the case of a leukoma, either the whole surface of the 
leukoma may be tattooed or only part of it; e.g., its center, 
in order to represent a pupil. 

The material used is fine India ink rubbed into a very 
thin paste. The eye having been cocainized, the leukoma is 
spread over with this paste, and then covered with innumer- 
able punctures by means of de Wecker' s multiple tattooing- 
needle, each stab of which carries into the corneal tissue 
some of the black pigment. The coloration continues 
sufficiently intense for some months, but then often begins 
to get pale, owing, probably, to the pigment falling out 
of the punctures. A better method of tattooing, by which 
the pigmentation lasts longer, is performed with de Wecker' s 
single- grooved needle. The pigment is placed in the groove 
of the instrument, which is then passed into the true cornea, 
a long canal being made in a plane parallel to its surface. 
On withdrawal of the needle the pigment remains behind. 
A large number of such canals must be made in close 
proximity to each other, until the desired intensity of color 
is obtained. 

In cases where the whole cornea is leukomatous, and, con- 
sequently, where no restoration of sight can be obtained by 



THE CORNEA. 207 

means of an artificial pupil, transplantation of a portion of 
clear cornea from a rabbit's eye, or from a freshly enucleated 
human eye, has been repeatedly performed by ophthalmolo- 
gists in various parts of the world. Very many of these 
operations have been perfectly successful in a surgical sense ; 
i. e., in so far as the healing-in of the transplanted flap was 
concerned ; but, with a few exceptions, they all ended in 
disappointment, in consequence of the flap not retaining its 
transparency. In the course of a week or two, the trans- 
planted portion invariably becomes as opaque as the leukoma 
had been before. The mode of proceeding consisted in 
removing a portion of the leukoma with a trephine, and then, 
with the same instrument, cutting a disc out of the clear 
cornea to be utilized, and inserting it into the opening in 
the leukoma. 

Various theories were formed to account for the occurrence 
of the opacity in the transplanted flap, but into all of these 
it is unnecessary to enter. Von Hippel "^ came to the conclu- 
sion that the onset of the opacity was due to the entrance 
of the aqueous humor into the substance of the cornea, 
owing to the solution of continuity in its posterior epithelium ; 
Leber's experiments f having shown that, unless this epithe- 
lial layer be intact, the transparency of the cornea cannot 
be maintained. Von Hippel, acting on this theory, applied 
a trephine to the leukoma as deep as the posterior elastic 
lamina, and then dissected off the superficial layers contained 
within the ring, leaving only the posterior elastic lamina 
and posterior epithelium. With the same trephine he then 
excised a disc of its entire thickness from a rabbit's cornea 
and applied it to the wound. Iodoform was dusted over this 
and a bandage applied. Healing took place readily, and 

* Bericht der Ophthal. Geselhchaft zu Heidelberg, 1886, p. 54. 
t A. von Gj-aefe' s Arc/iiv , Vol. xix, p. 87. 



2o8 DISEASES OF THE EYE. 

twenty months afterward the flap continued transparent, 
and vision = ^W- ^^^ Hippel has had some other suc- 
cessful cases. 

Arcus Senilis. — This is a change which is developed in 
the cornea without previous inflammation. It presents the 
appearance of a grayish line a little inside the margin of the 
cornea and all around it, most marked above and below, and 
never advancing further toward its center. It is most 
common in elderly people, but is sometimes seen in youth, 
and even in childhood. No functional changes are caused by 
it, nor does it interfere with the healing of a wound which 
may be made in that part of the cornea. Arcus senilis 
is caused by a hyaline degeneration of the corneal cells 
and fibrillae, and is not a sclerosis, as is stated by some 
authors. 

As an explanation for the restriction of this opacity to the 
periphery of the cornea, Gruber * suggests that it is due to 
the peculiar conditions of nutrition which prevail there, and 
which differ essentially from those that exist in the central 
regions of the cornea. He points out that, while in the 
peripheral zone there is a flow of nutritive material out of 
the arteries of the limbus toward the veins or toward the 
anterior chamber, the central regions of the cornea are 
sustained merely by their own vital tissue activity. In 
advanced life the blood-pressure is diminished, and the 
general condition of the circulation becomes more unfavor- 
able than heretofore, and with this the peripheral zone of 
the cornea must undergo changes in its nutrition which 
would be likely to promote degenerative changes in its tissue. 
On the other hand, the vital tissue activity alters but little, 
and hence the central regions of the cornea retain their 
transparency. That the very periphery of the cornea, even 



* Wien. Med. Woe hens c hr. , 1894, No. 4. 



THE CORNEA. 209 

in the most pronounced examples of arcus senilis remains 
transparent is explained, Gruber thinks, by its immediate 
contiguity to the vascular limbus, whereby it is not affected 
by diminished blood- pressure. 

Pigmentation of the Cornea. — A rusty brown discol- 
oration of the cornea, due to hematin granules, has been 
occasionally observed, associated with hemorrhage in the 
anterior chamber. A somewhat similar discoloration occurs 
in cases where particles of iron have been imbedded in the eye. 
Siderosis {ffldrjpoc;^ iron) is the name given to this latter con- 
dition. 



18 



CHAPTER VII. 
DISEASES OF THE EYELIDS. 

Erythema, erysipelas, phlegmonous inflammation, and ab- 
scess are all liable to attack the eyelids, but require no special 
observations in this work. It should merely be stated that 
erysipelas of the eyelids may extend to the connective tissue 
of the orbit, and ultimately give rise to atrophy of the optic 
nerve. 

Eczema. — This is very often seen on the eyelids, most fre- 
quently in connection either with eczema of the face in general 
or with phlyctenular ophthalmia, which latter is to be regarded 
as eczema of the conjunctiva and cornea. The lacrimation in 
phlyctenular ophthalmia increases the eczema, which then, by 
causing contraction of the skin of the lower lid, produces 
eversion of the inferior punctum lacrimale, and this, in its turn, 
causes increased lacrimation, and thus a vicious circle is set up. 

Atropin infiltration of the eyelid, from long use of solution 
of atropin in some persons, is often accompanied by a moist 
form of eczema of the lids and face. 

Treatment should consist in the daily removal of the scabs 
in such a way as to cause no bleeding of the surface under- 
neath ; and for this purpose a warm solution of bicarbonate of 
potash is useful. The place should afterward be well dried, 
and painted with a strong solution of nitrate of silver (gr. xx 
ad oj) and a boracic acid ointment (gr. xxx ad Sj), or the 
following, applied over this : 01. Cadin, tt^. xv ; Flor. Zinci, 
gr. XX ; LanoUn, 5ij- — M. If the inferior lacrimal punctum 
be everted the canaliculus should be slit up. 



THE EYELIDS. 211 

Herpes zoster ophthalmicus is a herpetic eruption which 
affects the region suppHed by the supraorbital division of the 
fifth nerve of one side, and sometimes its nasal branch, and in 
rare instances the infraorbital division of the same nerve. The 
occurrence of the eruption is preceded for some days by severe 
neuralgic pain and swelling, with redness of the part. The 
number of vesicles varies much, and may be but three or 
four, or so numerous as to become confluent. As soon as 
the eruption appears the pain usually becomes much dimin- 
ished, and, indeed, often disappears. Vesicles are liable to 
form on the cornea, and these may result in ulcers, which, on 
heahng, leave opacities. The keratitis and ulcers of the 
cornea are nearly always accompanied by more or less an- 
esthesia of the affected portion, which may persist for a very 
long time. Iritis has also been observed as a complication, 
and even cycHtis, resulting in loss of the eye. The vesicles 
on the skin soon become purulent, and gradually turn into 
scabs, which fall off and leave deeply pitted scars, recognizable 
during the remainder of life. The affection never crosses the 
middle line of the forehead. Some neuralgia, with anesthesia 
of the skin, may remain for a long time afterward. 

Inflammation of the Gasserian ganglion, with the extension 
of the inflammatory process down the nerve, was found (O. 
Wyss) in the only case in which a postmortem examination 
has been made during the acute stage of the disease. 

The affection is most common in elderly people, but I have 
seen it also in young and healthy individuals. 

Tlie treatnieni can only be expectant, or at most directed 
to relief of the patient's suffering by means of hypodermic 
injections of morphia and other sedatives, and by emollients 
applied locally. Complications in the cornea and iris are to 
be dealt with on the principles laid down in the chapters on 
the diseases of those organs. 

Primary syphilitic sores occur on the eyelids, usually near 



212 DISEASES OF THE EYE. 

the margin of the upper or lower Hd, or at the inner or outer 
can thus. The first appearance is generally a " pimple," which 
ulcerates and becomes characteristically indurated about its 
base. The margin of the ulcer is clean-cut, and its floor some- 
what excavated, and covered with a scanty grayish secretion. 
Occasionally there is no ulcer present, but the entire lid 
is swollen, greatly indurated, purple, and shiny ; and then 
the diagnosis may be rendered difficult. The preauricular 
and submaxillary glands are almost always swollen ; and 
this is a valuable, although not altogether positive, diagnostic 
sign, as it is seen also in tubercular diseases of the conjunctiva. 
The occurrence of the sore is followed by the usual consti- 
tutional symptoms of syphilis. Very rarely is there any 
permanent damage done to the eyelid. 

The most common modes of infection are by a kiss from a 
syphilitic mouth or by a dirty finger. 

Treatment. — Locally, sublimed calomel by Kane's method, 
dusting with finely-powdered iodid'of mercury, or the black 
wash may be used, while the usual general mercurial treat- 
ment is employed. 

Secondary syphilis gives rise to ulcers on the margins of 
the lids, to loss of the eyelashes (madarosis), and to the secon- 
dary skin affections which attend it in other parts of the body. 

In tertiary syphilis, ulcerating gummata of the lids some- 
times are seen, accompanied by remains of previous iritis or 
keratitis. 

Vaccine vesicles on the eyelids are produced by accidental 
inoculation at the intermarginal part of the lid ; or on the 
outer surface of the lid, if the skin be abraded by the finger- 
nail or otherwise. Sometimes the vesicle develops into a 
large ulcer with yellowish floor and hard and elevated 
margin. There is much pain, much swelling of the eyelid, 
and chemosis. 

Although distressing for a week or so while it lasts, the 



THE EYELIDS. 213 

affection is not a dangerous one further than that a cicatrix in 
the skin is left behind, and the eyelashes at the affected part 
are lost. 

Treatment. — A warm chlorate of potash lotion (gr. v ad §j) 
is the best application. 

Rodent Ulcer (Jacob's Ulcer). — This disease commences 
as a small pimple or wart on the skin near the inner canthus, 
or over the lacrimal bone, as a rule ; but it may also originate 
in any other part of the face. The scab or covering of the 
wart is easily removed, and underneath is found a shallow 
ulcer with a well-defined indurated margin, the skin surround- 
ing the diseased place being healthy, and continuing so to the 
end of the chapter. The progress of the disease is extremely 
slow, extending over a great number of years, and in the early 
stages the ulcer may even seem to heal for a time, but always 
breaks out again. In mild cases the ulceration may remain 
superficial ; but more usually it strikes deep, in the course of 
time eating away every tissue, even the bones of the face and 
the eyeball. The latter is often spared until after the orbital 
bones have gone. 

The disease is an epithelial cancer of a non-malignant or 
purely local kind. There is no tendency to infiltration of the 
lymphatics. It is rarely seen in persons under forty years of 
age. 

Treatment. — Extirpation of the diseased part affords the best 
chance of relief for the patient. Recurrence of the growth is 
the rule, but this should not deter from operative measures, 
nor even from the renewal of them, as they afford much com- 
fort to the patient and prolong his life. Even in advanced 
stages operation is frequently called for. The application of 
chlorid of zinc or of the actual cautery should be employed 
after the disease has been as thoroughly removed with the 
knife as is possible. 

Bergeon' s Treatment. — This consists in the internal adminis- 



214 DISEASES OF THE EYE. 

tration of five grains of chlorate of potash three times a day, 
with the local application of a saturated solution of chlorate 
of potash to the ulcer, and by aid of it remarkably good cures 
can be effected. It is well, in many cases, to scrape the ulcer 
before applying the solution. The process must be repeated 
daily, or at least every second or third day. It is certainly 
painful, but not unbearably so. Sometimes a green slough 
is produced, and when this is the case there is generally some 
surrounding inflammation, which should be allowed to subside 
a little before going on with the treatment. As the healing 
process does not begin until the diseased tissue has been re- 
moved, the progress may seem slow for the first week or fort- 
night, but no case resists the treatment if it be persevered 
with. While the chlorate of potash destroys the disease, it 
does not act injuriously on the delicate epithelium which be- 
gins to grow in from the margin as healing sets in, and it 
should therefore be continued until the whole surface has 
healed. Another fortunate peculiarity is that it has no effect 
on the normal conjunctiva, and may be used without fear if 
the latter be involved in the disease. 

Marginal blepharitis {pU(papov, eyelid), or ophthalmia 
tarsi, is nothing else than eczema of the margin of the eyelid. 
It is found either as blepharitis ulcerosa (eczema pustulosa), 
or as blepharitis squamosa (eczema squamosa). In the 
former, small pustules form at the roots of the eyelashes, and 
these, having lost their covering, become ulcers, which scab 
over. The whole margin of the lid may then be covered 
with one large scab, in which the eyelashes are matted, and 
under which the lid will be found swollen, red, and moist, with 
many minute ulcers and pustules. Many eyelashes come 
away with the scab, and others are found loose and ready to 
fall out. 

The disease is chronic, and is most commonly seen in 
strumous children. It is frequently accompanied by phlyc- 



THE EYELIDS. 215 

tenular ophthalmia, or by simple conjunctivitis, which may have 
been its cause, or which promotes it by keeping the margin of 
the lid constantly wet. 

If neglected, ulcerous blepharitis is liable to produce trich- 
iasis by giving a false direction to the bulbs of the cilia. 

Many ophthalmologists hold that blepharitis is often caused 
by ametropia, especially by hypermetropia or hypermetropic 
astigmatism, in consequence of the incessant efforts of accom- 
modation. I cannot go thus far ; but, perhaps, if blepharitis 
be once set up, such anomalies of refraction may help to keep 
it going. 

The treatment of iilceroiis blepJiaritis consists in careful 
removal of the scabs without causing any bleeding of the 
delicate surface underneath. Such bleeding indicates that the 
newly-formed epithelium has been torn away, and it is im- 
portant, therefore, to soften the scabs by soaking the eyelid 
with olive oil, or with a solution of bicarbonate of potash, be- 
fore removing them. Any pustules found under the scab 
should be punctured, and all loose eyelashes taken away, and 
the ulcers touched with a fine point of solid mitigated lapis. 
The surface should then be well dried by pressure, not by 
rubbing, with a soft cloth, and the following ointment (Hebra) 
applied : 

R. 01. rusci (or ol. juniperi), ^ss 

Hydrarg. ammon. chlor. , gr. iv 

Cer. galeni, 

Lanolin, aa ^ij. 

This ointment is to be continued until healing is thoroughly 
established. In many mild cases a boracic acid ointment (gr. 
V ad 5j of vasehn or of lanolin) will be found efficacious in- 
stead of the above, and a white precipitate ointment of from 
one to two per cent, acts well. A creolin ointment suits many 
cases, viz. : Creolin, ^j— v ; Aq., 5ij ; Lanolin, 5vj. 

Or, again, after the scabs and loose eyelashes have been re- 



2i6 DISEASES OF THE EYE. 

moved as above, the margins of the eyelids may be freely 
bathed with a wash of lo to 20 minims of creolin to eight 
ounces of water, as recommended by Dr. Glasgow Patterson 
for chronic eczema,* and after this the creolin ointment may be 
applied. I have found this method very successful. But in 
all cases, whatever the lotion or ointment ordered may be, the 
ulcers should be touched with mitigated lapis, as above recom- 
mended, and all loose eyelashes removed. 

All complications with conjunctival affections or lacrimal 
obstruction must be attended to, and the patient's general 
system carefully improved. Any error in refraction should be 
suitably corrected. 

Squamous blepharitis comes on after the ulcerous form has 
passed away ; or it is found as a primary affection, especially 
in chlorotic women. The margin of the lid is somewhat 
swollen and red, and covered with loose epidermic scales. It 
is an extremely chronic affection. 

TJie treatment of squamous blepharitis is also an ointment of 
Hebra's : 

R. Emplast. diachylon CO. , I 3 i j 

01. olivar, q. s. 

or the boracic acid ointment may be used. 

Chlorosis, if present, Is to have suitable remedies. 

Phtheiriasis {<pOeip, a loicse) Ciliorum. — The pediculus 
pubis occurs on the eyelashes. It gives rise to excessive itch- 
ing and burning sensations, and the consequent rubbing pro- 
duces excoriations of the margin of the lid. The lice occupy 
chiefly the roots of the eyelashes, while the shafts of the 
cilia are covered with their brown egg-capsules, and this 
gives to the cilia the peculiar appearance of being covered 

* Dub. Joiirn. Med. Sciences, July, 1 89 1. 

I Emplast. diachylon co. is made as follows : Emplast. litharg. , B. P., 12 parts ; 
cornflour, l^ parts; ammoniac, galbanum, turpentine, of each one part. 



THE EYELIDS. 217 

with dark brown powder, which enables the diagnosis to 
be easily made. The full)- developed parasites, as well as 
the eggs, may be more readily seen by aid of a strong 
convex glass. 

Treatment. — With a cilium forceps the pediculi may be, to 
a great extent, if not completely, removed, as well as some of 
the eggs from the cilia. This proceeding repeated daily, 
along with the application of mercurial ointment, or of a weak 
red precipitate ointment, to the margin of the eyelids morning 
and evening, will soon effect a cure. 

Hordeolum [hordeinn, a grain of barley), or stye, is a 
circumscribed purulent inflammation situated at the follicle of 
an eyelash. It commences as a hard swelling, with more or 
less tumefaction and edema of the general surfece of the lid, 
and often with some chemosis, especially if it be situated at 
the outer canthus. In its early stages there is much pain 
associated with it. It gradually suppurates, and may then be 
punctured or allowed to open of itself. 

Styes frequently come in rapid succession, one after the 
other, and then, probably, a constitutional disturbance exists 
as the cause. In the earliest stage cold applications may be 
successful in putting back a stye, but later on, warm stupes 
will hasten the suppuration and relieve the pain. Habitual 
constipation is a common source of hordeolum, and should 
be met by the occasional use of cascara sagrada, some aperient 
mineral water, or other mild laxative. Sulphid of calcium, 
^ gr. every hour, or i^ gr. twice a da}^, for an adult, has 
been recommended (D. Webster) as a specific in these cases. 

Chalazion {ydXa^a, hail), Meibomian cyst, or tarsal tumor 
is probably a granuloma in connection with a Meibomian 
gland, and not a mere retention cyst. Microorganisms * 



* Lagrange, " Tumeurs de Toeil,' ' etc. , Paris, 1893 '■> Eukala, Centralbl. f. p7-akt. 
Augen/ieil/c, October, 1S93 ; Parisotti, Annaies d' Oculist, June, 1893, p. 417. 



2i8 DISEASES OF THE EYE. 

have been found by some observers in these tumors, but what 
relation exists between them and the tumors is a matter upon 
which opinions differ. It has its origin in a chronic inflamma- 
tory process in the connective tissue surrounding the gland, 
which usually passes off without having attracted the attention 
of the patient. These tumors vary in size from that of a 
hemp-seed to that of a hazelnut, causing a marked and very 
hard swelling in the lid. They occasionally open spon- 
taneously on the conjunctival surface, giving exit to contents 
which are usually viscid or grumous, but sometimes purulent. 

Treatment. — No application can bring about absorption of 
these tumors. The lid should be everted, the tumor opened 
by a single incision from the conjunctival surface, and its con- 
tents thoroughly evacuated by aid of a scoop or small sharp 
spoon. Difficulty is sometimes experienced in finding the 
point in the conjunctiva corresponding to the tumor, but it is 
usually indicated by a dusky or grayish discoloration. Im- 
mediately after the evacuation bleeding into the sac often takes 
place, and causes the tumor to remain for a day or more as 
large as before, a fact of which the patient should be warned. 
The operation may occasionally require to be repeated two or 
three times. The interior of the sac should not be touched 
with nitrate of silver ; and the incision and evacuation should 
never be made through the skin, because more or less dis- 
figurement from the scar would result. 

More than one chalazion is often present at a time, and 
some people become liable to them periodically during a 
number of years. 

Milium {niiliitni, a millet seed) presents the appearance of 
a perfectly white tumor, not much larger than the head of a 
pin, in the skin of the eyelid. It is a retention tumor of a 
sebaceous gland, and can readily be removed by puncture and 
evacuation. 

MoUuscum, or Molluscum Contagiosum. — This is a 



THE EYELIDS. 219 

white tumor in the skin of the eyelid, which may attain the 
size of a pea. At its summit is a depression, which leads to 
an opening into the tumor, through which the contents can be 
pressed out. It is probably a diseased condition of a sebaceous 
gland, and contains altered epithelial cells, and peculiar bodies 
termed molluscum corpuscles, which are of a fatty nature. 
Many such tumors may form in the lids at the same time. 

It is held by some observers that this affection is con- 
tagious, although in what way is not clear, inasmuch as ex- 
perimental rubbing of the contents of a molluscum into the 
skin has not given rise to the tumors. 

Treatvient. — Each separate tumor must be evacuated by 
simple pressure, or after it has been opened up with a knife or 
scissors. 

Telangiectic tumors, or nevi, of the eyelids occur con- 
genitally. 

Treatment. — Small tumors of this kind may be destroyed by 
touching with nitrate of silver or hydrochloric acid or by per- 
forming vaccination on them. Larger tumors may be liga- 
tured or treated with the galvano-cauter}', and electrolysis is a 
very effectual method in many cases. 

Xanthelasma ^^avdoq, yellow ; sXaaixa, a layer) is the term 
applied to yellowish plaques raised slightly over the surface 
of the skin, with ver}^ defined margins. The patches are 
generally bilateral and symmetric, and are most frequently 
situated in the neighborhood of the inner canthus. The 
shape of these plaques is extremely irregular, and they may 
attain the size of a shilling or larger. The appearance is 
caused by hypertrophy of the sebaceous glands, with retention 
of their contents, and fatty degeneration of the subcutaneous 
connective tissue. 

Treatment can only consist in removal by careful dissection, 
and this is hardly to be recommended except in extreme 
cases. 



220 DISEASES OF THE EYE. 

Palpebral Chromidrosis {y^pihim, color ; 'idpojatq, sweat- 
ing). — The phenomenon of an exudation of pigment upon the 
eyehds, of which about 50 cases have been recorded, has 
given rise to much discussion. The opinion held by many is 
that these cases are always the result either of deception in 
hysteric individuals, or of accidental circumstances, such as 
the exposure of a patient with seborrhea palpebrarum to an 
atmosphere loaded with coal-dust or pigmentary matter, in 
some manufacturing district. Of the fact that the appearance 
has occurred under both of these conditions there can be no 
doubt. There would seem also to be evidence that some 
genuine cases of color-sweating on the eyelids have been ob- 
served ; but they must be extremely rare. The discoloration 
is blue or black, and occurs in the form of fine powder upon 
the skin of one or both eyelids of both eyes. It can be wiped 
off, and is said to begin to reappear after a short interval. The 
subjects of it have been chiefly young girls, but it has also 
been seen in women of advanced years and even in middle- 
aged men. 

TJie treatment in a genuine case may consist in the applica- 
tion of a lotion of liq. plumbi and glycerin ; and, internally, 
iron, quinin, and arsenic, along with the regulation of the 
general system, particularly in respect of any uterine derange- 
ment. 

Epithelioma, sarcoma, adenoma, and lupus are all seen 
in the eyelids, but require no special description here. 

Clonic cramp of the orbicularis muscle, or of a portion 
of it, is often seen, and is popularly known by the name of 
'' life " in the eyelid. It is frequently due to overuse of the 
eyes for near work, especially by artificial light, or if there be 
defective amplitude of accommodation. 

Treatment should consist in the regulation of the use of the 
eyes for near work, and the correction by glasses of any de- 
fect in the accommodation. 



THE EYELIDS. 221 

Blepharospasm, or tonic cramp of the orbicularis 
muscle, is commonly the result of irritation of the ophthalmic 
division of the fifth nerve by reflex action, as in phlyctenular 
ophthalmia and some other corneal and conjunctival affections ; 
or from foreign bodies on the conjunctiva or cornea, etc. ; or 
it may continue for some time after the relief of any such 
irritation. It occurs, also, independently of such causes, and 
is then difficult to account for, unless as a hysteric symptom. 
Yet ev^en in these obscure cases, the spasm is probably often a 
reflex from the third nerve, and it will be found that pressure 
upon the supraorbital nerve at the supraorbital notch may arrest 
the spasm ; or, if not there, then pressure on the infraorbital, 
temporal, malar, or inferior alveolar branch may have the de- 
sired effect ; or at even still more remote regions, and in the 
course of other nerves, the pressure point may be discovered. 

Treatment. — If the cause of the reflex cannot be ascertained 
or has passed away, and the cramp be very distressing, 
stretching or resection of the branches of the fifth nerve, from 
which the reflex proceeds, may be tried. Morphin hypoder- 
mically has been of use in some cases, but it would be undesir- 
able to continue this treatment for long. 

Ptosis {TZTwaiq^ a fall), or blepharoptosis, is an inability to 
raise the upper lid, which then hangs down over the eyeball. 
It is either congenital or acquired, and in the latter case is 
most usually the result of paralysis of the branch of the third 
nerve supplying the levator. 

Persons affected with ptosis involuntarily endeavor to raise 
the eyelid by an overaction of the frontalis muscle. The 
drooping lid and elevated eyebrow give a peculiar and char- 
acteristic appearance. 

The causes of paralytic ptosis are similar to those of paralysis 
of other branches of the third pair, more especially exposure 
to cold drafts of air while the body is heated, and syphilis 
or rheumatism affecting the branch to the levator palpebrse in 



222 DISEASES OF THE EYE. 

its course. It may also be due to cerebral disease.* The 
branch to the levator may be paralyzed alone or in conjunc- 
tion with other third nerve branches, and the loss of power 
may be partial or complete. 

TJie treatment of a recent case of ordinary paralytic ptosis 
depends upon its cause. If this be syphilis, then a course of 
mercurial inunctions or of iodid of potassium ; if rheumatism, 
then salicylate of soda or iodid of potassium, with, in either 
case, protection of the eye and side of the head with a warm 
bandage. Cases in which these remedies have failed, and 
which have become chronic, often demand operative treat- 
ment. Attempts have been made, with success in some cases, 
to obviate the inconvenience of ptosis by giving support to 
the lid by wire splints worn like an eyeglass or attached to 
the upper edge of spectacle frames. 

Ptosis due to a cerebral lesion rarely comes within the scope 
of treatment.* 

Operative treatment is indicated in cases of paralytic ptosis 
— where other measures have produced no result — in ptosis 
adiposa, and in congenital cases. A very common proceed- 
ing consists in the excision of a sufficiently large oval piece of 
integument, its long axis lying in the length of the lid, with 
the subcutaneous connective tissue and fat, and, in paralytic 
cases, a small portion of the orbicular muscle. The fold of 
integument to be abscised is seized by two pairs of forceps — 
one of them held by an assistant — at the inner and outer ends 
of the lid, and by this means the necessary size of the fold is 
estimated. The abscision is performed with a pair of scissors, 
the margin of the wound lying close to the points of the for- 
ceps. The subcutaneous tissue, etc., is then removed, and the 
edges of the wound drawn together by a few points of suture. 



*The value of ptosis as a localizing symptom in cerebral disease will be 
treated of in Chap, xviii. 



THE EYELIDS. 223 

Pagenstecher' s inetJwd is as follows : Its object is to 
enable the patient to derive more benefit from the effort of 
his frontalis muscle, which he is constantly making with so 
little result, by transferring its action more directly to the 
eyelid. A needle carrying a thick ligature is entered under 
the skin of the forehead about J^ of an inch above the center 
of the eyebrow, and passed subcutaneously as far as the mar- 
gin of the eyelid at its middle point. The suture is closed, 
not very tightly at first, but each day somewhat more tightly, 
until it has cut its way through the skin. As the result of 
this a cicatrix is formed in the course of the ligature, which 
gives the frontalis much more power over the eyelid. I have 
tried this method, but I have not been satisfied with it. 

Birnbaclicr s operation is an improvement on former attempts 
to connect the tarsus with the frontalis by cicatrices. An in- 
cision, with its convexity upward, is made in the skin, corre- 
sponding to the upper edge of the tarsus. Three sutures w ith 
a needle at each end are passed through the upper border of 
the tarsus, so as to form three loops, one central and two 
lateral ; the two needles of the central loops are passed verti- 
cally upward under the skin, and are brought out quite close 
to one another in the eyebrow. The lateral loops are treated 
in the same way, but are made to diverge on each side from 
the central one, instead of being parallel. The ends of the 
threads are tied over a small roll of lint, and tightened until the 
edges of the lids just touch when the patient closes the eye. 
They may be left in from twenty to twenty-five days.* 

Pmias' Met]iod.\ — The object of this operation is to bring 
about a union between the lid and the frontalis muscle by 
forming a flap in the former, which is fastened to the skin of 
the forehead and to the surface of the muscle. 

* Centralblatt. f. prakt. Augenheilk., 1892, p. 129. 

■\ Archives a' Ophthalmologie , January — February, 1886. 



224 



DISEASES OF THE EYE. 



Before the operation commences, and while it is in progress, 
an assistant appHes his hand firmly to the patient's forehead, 
in such a way as to prevent shifting of the skin of the eyelid 
over the underlying tissues, which would interfere with the 
exactitude of the proceeding. 

A horn lid-spatula is inserted under the lid. Figure 6i 
explains how the eyelid flap is formed. The horizontal incision 

along the top of the flap 
has a slight convexity up- 
ward, is not quite an inch 
long, lies over the orbital 
margin, and goes through 
all the tissues down to the 
periosteum. Another in- 
cision, parallel to this one, 
rather more than an inch 
long, is made along the 
upper border of the eye- 
brow and as deep as the 
periosteum. The flap of 
skin and muscle is now 
dissected from the tarsus 
down to its ciliary border, 
but the suspensory liga- 
ment of the lid must not 
be interfered with. The 
bridge of tissue between the two horizontal incisions is 
now to be undermined without injury to the periosteum or 
suspensory ligament. The flap is then drawn up under the 
bridge by means of the sutures {a a^), and secured to the 
upper edge of the upper incision. Inasmuch as the traction 
exercised by the flap when so fixed tends to produce ectropion 
of the lid, two lateral sutures (d b') are applied deeply through 
the suspensory ligament and conjunctiva to the exclusion of the 




Fig. 6i. 



THE EYELIDS. 



225 



skin, and are attached, like the other sutures, to the upper hp 
of the upper incision, thus counteracting the tendency to ec- 
tropion. Figure 62 shows the effect of the operation. 

Fuchs has pubhshed * some cases of bilateral ptosis in 
elderly people, which were due, in his opinion, to primary 
atrophy of the levator palpebrse muscles. The eyelids were 
elongated and thinned, so that the eyeball showed plainly 
through them. The loss of power had in each case been very 
slowly increasing for many years. 

Congenital ptosis is generally present in both eyes. It is 
due in some cases to an 
imperfect development of 
the levator palpebrse, and , 
in others to an abnormal 
insertion of this muscle, 
its tendon being attached 
to the tarsus too far 
back. Either Birnbach- 
er's or Panas' operation 
may be employed here. 
Eversbusch has pro- 
posed f the following pro- 
ceeding more particularly 
for congenital ptosis : 

Evei'sbiiscli' s Operation for Congenital Ptosis (Figs. 63 and 
64). — The object of the operation is to increase the power of 
the levator by advancing its insertion, or rather by doubling 
it down over the tarsus, to which it forms fresh adhesions. 
Snellen's lid-clamp is applied, so that the plate is passed well 
up into the fornix ; and before the ring is screwed down the 
skin of the lid is drawn down, so that its prolongation just 




Fig. 62. 



* Von Graefe's Archiv, xxxvi, i, p. 234. 
^ Monatsbl. f. Augenheilk., 1883, p. loo. 



226 



DISEASES OF THE EYE. 



under the eyebrow may be forced into the instrument. The 
skin and the underlying orbicularis are now divided in the 
entire width of the lid, parallel to its free margin, and at 
a distance half-way between this margin and the eyebrow. 
The skin and the subjacent muscle are then separated up, both 
upward and downward, for four mm. in each direction, so that 
the insertion of the levator may be well exposed. A suture 
with a small curved needle at either end is then introduced, 




Fig. 63. Fig. 64. 

/. Levator palpebrae. 0. Orbicularis. 



by means of one of these needles, horizontally into the tendon 
at its insertion, and near the center of the latter, in such a 
way that about 2 i^ n^^i- of the tendon may be included in 
the suture. Each needle is now passed vertically downward 
between the tarsus and orbicularis, and brought out at the 
free margin of the lid at a distance from each other of about 
2 J^ mm. Two more such double sutures, one in the temporal, 
the other in the nasal, third of the tendon are similarly applied. 



THE EYELIDS. 



227 



The margins of the horizontal skin and muscle wound are 
now drawn together, and then the three sutures are closed 
tightly. It is desirable to slip glass beads over the ends of the 
sutures before tying them, to prevent cutting into the margin 
of the lid. Both eyes are bandaged, and the sutures left in for 
a week or more. 

Hugo Wolff ' s operations for congejiital ptosis * by advance- 
ment of the levator palpebrae superioris : 

Method I (Fig. 65). — An incision of about two cm. in 
length is made through the skin of the upper lid in a position 




Fig. 65. 

corresponding to the upper border of the tarsus, and the lips 
of the wound are each dissected up for a distance of three 
mm. By this means the orbicularis is laid bare. In the 
center of the wound, and at the upper margin of the tarsus, a 
fold of the orbicularis of about one cm. in width, with the sub- 
jacent levator tendon, is seized in the forceps. This fold is 
isolated in a vertical direction by a few strokes with the scis- 



Arch. f. Augenheilkunde , xxxiii, i and ii, August, 



228 DISEASES OF THE EYE. 

sors, and is undermined. Two strabismus hooks are then 
passed under it, and placed so that one of them hes close to 
the insertion of the levator tendon into the tarsus.* The 
amount by which it is desired to raise the lid is measured off 
on the tendon from its insertion, and Schweigger's strabo- 
meter is convenient for this purpose. (If, for example, the pal- 
pebral opening in the normal eye is ten mm., while that in the 
eye to be operated on is three mm., it will be required to raise 
the drooping eyelid seven mm.) ' At the point found by this 
measurement two sutures, each with two needles, are applied 
in the muscle, and the latter is divided immediately below the 
ligatures. The four needles are then passed through the 
stump of the tendon at its insertion, and through the portion 
of orbicularis which covers it ; the sutures are tied, and cut 
off short, and the skin wound is then closed by a few sutures. 
Method 2. — From the conjunctival surface. The eyelid is 
everted in the usual manner ; the upper margin of the tarsus 
is then seized in the double-legged fixation forceps, and the 
lid is rolled over again, and by this means the field of opera- 
tion is brought into view. To prevent bleeding a lid-clamp 
is now applied. On the right margin (as looked at by the 
operator) of the field of operation a fold of conjunctiva is 
raised and divided vertically, and the conjunctiva is under- 
mined upward, downward, and to the left, and divided by a 
horizontal incision about two cm. in length. The conjunc- 
tival flaps are turned upward and downward, and then the 
levator, with Miiller's muscle lying on it, are exposed to view. 
With the forceps, a portion in the center of the muscle, about 
one cm. wide, is seized and isolated from its bed by a few 
vertical strokes with the closed scissors. Two strabismus 
hooks are inserted under the isolated portion of muscle, one 



^ H. Wolff states that be finds the insertion of this tendon is five mm. below 
the upper margin of the tarsus. 



THE EYELIDS. 229 

ot them lying close to the convex margm of the tarsus, and 
then the clamp and fixation forceps are removed. In place of 
the strabismus hooks Wolff's spatula with millimeter scale 
engraved on it can be used. At the desired distance from the 
upper margin of the tarsus (which must precisely represent the 
difference between the palpebral opening in the sound eye and 
that in the faulty e}'e) two catgut sutures, with two needles 
each, are tied in the muscle, so that each knot will include more 
than half of the isolated portion of the muscle. The muscle 
is then divided close below the point of ligature ; the needles 
are passed through the stump close to the upper margin of the 
tarsus, which is also included ; the sutures are closed and cut 
off short. The conjunctival wound is then also closed. 

A remarkable condition is congenital ptosis^ witli associated 
movements of the affected eyelid, during the action of certain 
muscles. There are only about 30 cases of this on record. 
It is most commonly the left lid which is affected, and the 
paralysis may be congenital or acquired. Three conditions 
have been observed, viz. : elevation of the drooping lid when 
'the eye is adducted, Avhen the eye is abducted, or when the 
mouth is open. A synchronous contraction of the pupil has 
been noticed in some cases, while in some the elevation of the 
lid occurs also, with a lateral motion of the jaw and with de- 
glutition. Gower's explanation is that in these cases the 
levator is not wholly supplied by the third nerve, but partly 
also by nerve-fibers which, in the third variety, take their origin 
in the nucleus of the fifth pair, and which also supply the ex- 
ternal pterygoid and digastric muscles. But this theory does 
not hold good in all cases, for Bull '^ describes a case in which 
the Hd was also raised when the head was bent back, thus 
stretching the digastric. He regards these as associated or 
reflex mo\-ements. In some instances the lid can be raised 

''^ A 7- chives of Ophthalni., xxi, p. 354. 



230 DISEASES OF THE EYE. 

voluntarily on closing the other eye. Needless to say, no 
remedy can be applied for relief of this condition. 

The term ptosis is also given, although not very correctly, 
to cases in which increased weight of the lid causes it to droop, 
as in conjunctival affections, or where a tumor has formed in 
the eyelid, or where there is a hyper-development of the sub- 
cutaneous fat. 

Lagophthalmos (^Xay^q, a hare, as it was supposed that this 
animal sleeps with its eyes open ; ofdaXixdq), or inability to 
close the eyelids, is most commonly due to paralysis of the 
portio dura, and is then associated with the other symptoms 
of the latter affection. On an effort to close the lids being 
made, the eyeball is rotated upward under the upper lid, owing 
to the associated action of the superior rectus ; and in sleep 
this upward rotation also occurs, a fact which explains, to a 
great extent, the immunity of the cornea from ulceration in 
many of these cases. Lagophthalmos may also be due to 
orbital tumors pushing the eyeball forward, to exophthalmic 
goiter, to staphyloma, or to intraocular growths distending the 
walls of the eyeball — in all of which conditions the eyelids are 
often mechanically prevented from closing over the eyeball, or 
can be closed only by a strong effort of the will. The danger 
to the eye depends upon the tendency to ulceration of the 
cornea from its dryness, caused by exposure to the air, and 
from foreign substances not being removed from it by nictita- 
tion. 

When lagophthalmos occurs as a symptom in focal cerebral 
disease it is useful in localizing the disease by assisting in differ- 
entiating a lesion in the internal capsule, or in the facial motor 
center of the cortex, from one implicating the portio dura in 
the pons, as it is absent, or very slight, in the former cases, 
but very often markedly present in the latter. With a lesion 
in the lower part of the pons we are apt to have lagophthalmos 
with crossed hemiplegia ; but if the lesion be in the upper part 



THE EYELIDS. 231 

of the pons — the fibers from the opposite side having here 
joined the motor tract — the hemiplegia and lagophthalmos 
will be homonymous. 

Treatment. — In cases of non-paralytic lagophthalmos, pro- 
tection of the cornea by keeping the eyelids closed with a 
bandage, or a few epidermic sutures in the margins of the eye- 
lids, should be our first care. Tarsorrhaphy ma}- be employed 
in those cases where circumstances indicate that it would be 
useful — e.g., in some cases of exophthalmic goiter or of 
staphylomatous e}'eball. 

In paralytic cases, the primary cause of the paralysis (syph- 
ilis, rheumatism, etc.) must be treated so long as there is a 
prospect of restoring power to the muscle. Localh', galvan- 
ism and hypodermic injections of str\xhnia may be emplo}-ed. 
During cure the cornea should be protected as above. In in- 
curable cases, the opening of the eyelids must be reduced con- 
siderably in size by an extensive tarsorrhaphy. 

TJie operatio7i of tarsorrliapJiy consists in uniting the margins 
of the upper and lower lids in the neighborhood of the exter- 
nal commissure, so as to reduce the size of the opening of 
the eyelids. The commissure should be caught between the 
finger and thumb, and the edges of the lids approximated, 
so as to enable the operator to form an estimate of the re- 
quired extent of the operation. A horn spatula is then 
passed behind the commissure, and the necessar}' length of 
the margin of each lid, includincr the bulbs of the ciHa, ab- 
seised with a sharp knife. The raw margins are then brought 
together with sutures. 

Symblepharon (ah^., together ; [iXicsapo'^^ the eyelid) is an 
adherence, partial or complete, of the eyelid to the e}'eball. 
It is usually the result of burns of the conjunctiva b}- fire, 
acids, or lime. The shortening of the conjunctival sac. which 
is seen as the result of pemphigus or of granular ophthalmia, 
and which I have above described under the headino- of xer- 



232 



DISEASES OF THE EYE. 



ophthalmos, is sometimes, but I think wrongly, called sym- 
blepharon. If the symblepharon interfere seriously with the 
motions of the eyeball, or if it cause defect of vision by ob- 
scuring the cornea, it becomes desirable to relieve it by opera- 
tion. Should it consist of a simple band stretching from lid 
to eyeball it may be severed by ligature, and if the band be 
broad two ligatures may be employed, one for either half. 
A symblepharon which occupies a considerable surface cannot 
be got rid of in this way, and for such cases a transplantation 
procedure, like that of Teale * or of Knapp,t may be employed, 
the great difficulty in dealing with these cases being the ten- 
dency there is to reunion of the surfaces, unless one or both 
of them be carpeted with epithelium. 

In Teale s operation, if we suppose the case to be similar to 





Fig. 67. 



that represented in figure 66, J an incision is carried along the 
line of the margin of the cornea at A, through the whole thick- 
ness of the symblepharon, and the lid is dissected off from 
the eyeball as far as the fornix. Two conjunctival flaps are now 
formed, as at B and C in figure 67, and one of them (IT) is 
turned to form a covering for the wounded surface of the in- 
.side of the eyelid, while the other [C^ is used to cover the 



* Ophthal. IIosp. Rep., Vol. iii. 
■\ Arckiv f. Ophthal., xiv, pt. i, p. 270. 

J Mr. Teale now makes his flaps, as in Fig. 67, wider than he originally did. 
I have to thank him for altering this drawing with his own hand for this work. 




THE EYELIDS. 233 

bulbar surface (Fig. 68), the flaps being held in their places 
by fine sutures. That part of the symblepharon which is left 
adherent to the cornea soon atrophies and disappears. No 
great tension of the flaps should exist as they he in their new 
positions. 

Teale, again, has suggested the formation of a bridge-like 
conjunctival flap above the cornea, and the removing of it 
across the latter to cover the loss of substance situated below. 
After the sutures to keep the flap in its place have been intro- 
duced the latter is separated at its bases. 

A simple plan, which would ^^^UJJjji^ 

be applicable to such a case as -^^^"^ ^^5^, 

that depicted in figure 66, where 
the adhesion is not very extensive, 
and perhaps even to some more 
extensive ones, consists in dissect- 
ing the conjunctival process off the Fig. 68. 
cornea, and then turning it down 

on the raw inner surface of the under lid, and fastening it 
there with a suture or two. I have done this with complete 
satisfaction. 

The transplantation of a portion of rabbit's conjunctiva, as 
suggested by Wolfe, or of a portion of mucous membrane 
from the lips or from the vagina, as employed by Stellwag, is 
undoubtedly the best method for many cases of extensive 
symblepharon. The chief precautions necessary for success 
in this proceeding are : That the flap to be transplanted be not 
applied in its new position until all bleeding at the latter place 
has ceased. That the flap be nothing more than mucous 
membrane, all submucous tissue being carefully removed. 
That it be sufficiently large to cover the defect without any 
stretching ; and it should be remembered that the flap shrinks 
to two-thirds of its size after being detached from its own bed. 
That the flap be kept moist and warm during the period — as 



234 



DISEASES OF THE EYE. 




short as possible — which may elapse between its detachment 
and its adjustment. And, finally, that it be kept firmly in 
its new position by a sufificient number of points of interrupted 
suture. 

Harlan' s Operation.'^ — This is specially applicable to exten- 
sive symblepharon of the lower lid, and differs from the fore- 
going operations in that it provides a covering of skin, and 
not of mucous membrane, for the raw surface of the under lid. 
Operations on the same principle have been proposed by 
Snellen and by Kuhnt. An incision (A B, Fig. 69) through 
the whole thickness of the eyelid, and corresponding in 
length to the latter, is made along the lower margin of the 
orbit. Below this a skin-flap (C D) is then formed. The flap 

is dissected up, and the incisions 
are carried a little more deeply as 
A B is approached to enable the 
flap to turn the more readily. The 

''"~-^- __-— — ^V— __£ flap is then turned up as on a 

\ > ^^^' hinge, slipped through the button- 

Pj^ g hole, and sutured securely to the 

inner surface of the under lid. 
After a time, the skin surface turned toward the eyeball be- 
comes considerably modified, so as to be somewhat like 
mucous membrane. The bare space left by the removal of 
the strip of skin is covered without strain by making a small 
horizontal incision (D E) at its outer extremity, and forming 
a sliding flap. 

Blepharophimosis {pUcpapov^ eyelid : (piij-oxnq, narroivmg) is 
a contraction of the outer commissure of the lids, with conse- 
quent diminution in size of the opening between the latter ; 
and is commonly due to shortening of the skin, from long- 
continued irritation of it, caused by the discharge in a case of 
conjunctivitis. 

* Ophth. Rev., Vol. ix, p. 351. 



THE EYELIDS. 



235 



It is remedied by a cantJwplastic operation. The outer com- 
missure is divided in its entire thickness, in a line which is a 
prolongation of the line of junction of the lids when closed, by a 
single stroke of a strong straight scissors, one blade of which 
has been passed behind the commissure. The integumental 
incision should be made a little longer than that in the con- 
junctiva. An assistant then drawls the upper lid up and the 
lower lid down, so as to make the wound gape. The conjunc- 
tival margin and the dermic margin are now^ united in the 




Fig. 70. — <yDe Wecker.) 



center by a point of suture (C, Fig. 70), while two more sutures 
(A and B) are applied, one above and the other below the 
first. This operation is also employed in cases of granular 
ophthalmia and of purulent conjunctivitis when it is desired to 
reheve the pressure of the lid on the globe. 

Distichiasis {p\^, timce ; anyoc;, a rozv), and Trichiasis 
(rpiyoq, a hair). — The first of these terms indicates the growth 
of a row of eyelashes along the intermarginal portion of the lid 
in addition to the normal row ; while trichiasis indicates a false 



236 DISEASES OF THE EYE. 

direction given to the true cilia. Both conditions are often 
found coexisting, and they are also often present along with 
entropium. They may both be produced by chronic blepha- 
ritis or by chronic granular ophthalmia. It has been com- 
monly held that cicatricial contraction, giving a false direction 
to the hair-follicles, is the immediate cause of these conditions ; 
Raehlmann has recently * shown that the false cilia are de- 
veloped as buds or offshoots from the follicles of the cilia, and 
primarily from the cuticle of the free margin of the lid. The 
latter mode of development is a novel discovery by Raehl- 
mann, which he seems to have definitely proved by his patho- 
logic investigations. His view is that hyperemia of the 
margins of the lids and inflammation of a proliferating type are 
what give rise to this primary development of hairs. The 
symptoms they produce, and the dangers to the eye attendant 
on them, are due to the rubbing of the irregular eyelashes on 
the cornea, which produces pain, blepharospasm, and opacity 
of the cornea, or even ulceration of it. 

Operations for distichiasis and trichiasis : 

Epilation. — The false cilia may be pulled out with a forceps ; 
but this cannot be regarded as a cure, for the hairs grow again. 

Electrolysis has been proposed by Dr. Charles Mitchell, of 
Missouri, t and by Dr. A. Benson, of Dublin. J A needle is 
attached to the negative pole, and its point passed into the bulb 
of the eyelash to be removed, the positive pole being placed 
on the temple. On closure of the circle, if the battery be 
working properly, bubbles of gas should rise up round the 
needle, and a slough forms at the root of the hair, which be- 
comes loose and is removed. It does not grow again, for the 

* Von Graefe's Archiv, xxxvii, ii, p. 66. 

f " Trichiasis and Distichiasis, their Nature and Pathology, with a Radical 
Method of Treatment ; " and Klin. Monatsbl., April, 1882. 
XBrit. Med. Journal, December 16, 1882. 



THE EYELIDS. 237 

bulb is destroyed. Each hair must be separately operated on. 
The proceeding is very valuable where only a few cilia are to 
be dealt with. 

Illaqiieation. — Snellen has revived this ancient operation for 
cases where only a few isolated hairs are out of order. Both 
ends of a bit of very fine silk thread are passed through the 
eye of a fine needle so as to form a loop. The needle is now 
entered as close to the point of exit of the hair as possible, and 
the counterpuncture is made in the position which the hair 
should normally occupy in the row of its fellows. The needle 
is drawn completely through, as also the ends of the thread, 
but the loop not as yet. Into the loop the eyelash is now in- 
serted by aid of a fine forceps, and by traction on the ends of 
the thread, loop and eyelash are drawn through the tunnel. 
Unfortunately the eyelashes frequently regain their abnormal 
position by reason of their own elasticity. 

Excision. — When some half-dozen hairs close together are 
growing wrong, the simplest and best plan is to completely 
remove them by excision of the corresponding portion of the 
ciliary margin. A fine knife is passed into the intermar- 
ginal region at the place corresponding to the hairs to be 
dealt with, and a partial division of the lid into two layers, 
as in the Arlt-Jaesche operation (indc infj-a), is effected. A 
V-shaped incision in the skin of the lid is then made, includ- 
ing the erring hairs, the whole flap is excised, and the margin 
of the loss of substance drawn together with sutures. 

In cases of distichiasis or trichiasis involving the whole 
length of the eyelid, removal of the marginal portion of skin 
containing the bulbs of all the eyelashes, true and false 
(Flarer's operation), is not to be recommended — unless, occa- 
sionally, in the under lid — because it unnecessarily deprives 
the eye of an ornament and of a protection against glare of 
sun and foreign bodies. 

Transplantation, or shifting, of the marginal portion of the 



238 



DISEASES OF THE EYE. 



integument containing the hair-bulbs, true and false, is a pref- 
erable proceeding in these complete cases. One of the oldest 
and most valuable operations of this kind is that of Jaesche, 
modified by Arlt. It is performed as follows : Knapp's or 
Snellen's clamp (Fig. 71) having been applied to prevent 
bleeding, the lid in its whole length is 
divided in the intermarginal part into 
two layers (Fig. 72), the anterior con- 
taining the orbicular muscle and in- 
tegument with all the hair-bulbs, the 
posterior containing the tarsus and 
conjunctiva. The incision in the inter- 





FiG. 71. 



Fig. 72. 



marginal portion is about five mm. deep. A second incision 
is now made through the integument of the lid, parallel to its 
marcrin, and from five to seven mm. removed from it. This 
incision also extends the whole length of the lid. A third 
incision is carried in a curve from one end to the other of the 



THE EYELIDS. 239 

second incision. The height of the curve is proportional to 
the. effect required, varying from four mm. to seven mm. The 
piece of integument included between the second and third 
incisions is dissected off with forceps and scissors, without any 
of the underlying muscle being touched, and the margins of 
the loss of substance are brought together by sutures. By 
this procedure the lower portion of integument containing the 
hairs and their bulbs is drawn up and away from contact with 
the cornea. 

Spencer Watson,* Nicati,t Schoeler,t Burchard,§ Dianoux,|| 
and Gayet T[ have all proposed double transplantation opera- 
tions . 

Diaiioux' s operation is as follows : Snellen's or de Wecker's 
clamp is applied (omitted in figures for simplicity), and an 
incision (Fig. 73) is made parallel to the free margin of the 
lid, about four mm. from it, extending the whole length of the 
lid, and penetrating to the tarsus, but not through the latter. 
The ciliary portion of the lid marked off by this means is now 
detached from the tarsus by an incision in the intermarginal 
portion of the Hd, as in the Arlt-Jaesche operation. An 
incision through the skin alone is then made about three mm. 
above the first incision and parallel to it, but extending some 
two mm. beyond it at either extremity. The skin-flap is 
separated off from the underlying muscle, except at either 
end, where it is left attached. The underlying portion of the 
muscle is then separated from the tarsus, and allowed to 
retract upward. A forceps, being passed under the ciliary 
flap (Fig. 73), the skin-flap is seized and drawn down into 
the position of the former (Fig. 74), where it is made fast by 
three sutures to the margin of the tarsus. The ciliary flap is 

^ Ophthal. Hosp. Rep., Vol. vii, 1873, P- 440- t Marseille Medicale, 1879. 

\ Klinischer Bericht, 1880. \ Charite Annalen, p. 633. 

II Annales d' Oadistiqtie, 1882, p. 132, \ Ann . d' Oc2il., 1882, p. 27. 



240 



DISEASES OF THE EYE. 



moved up, and carefully stretched upon the tarsus bared ol 
the orbicularis, the latter being drawn back with a strabismus 
hook, and the flap is secured in its place by sutures to the 
tarsus. An antiseptic dressing is applied, and the sutures 
may be removed on the third day. Although the wounded 
surface of the ciliary flap does not become vitally united with 
the epidermic surface of the skin-flap, yet no practical ill 
result follows. 

A real objection lies in the circumstance that occasionally 
the cutaneous hairs on the transplanted flap irritate the cornea, 





Fig. 73. 



Fig. 74. 



and these hairs being much finer than cilia, are more difficult 
to deal with. 

Vosshis' Operation.^ — If, for example (Fig. 75), the whole 
extent of the right upper lid be affected with trichiasis, a horn 
Hd-spatula (the clamp will not answer) is passed under the lid, 
and held by an assistant. An intermarginal incision is made, 
as in the Arlt-Jaesche operation, about three mm. to four mm. 
deep. This incision is then prolonged through the skin 
merely, over the external commissure for five mm. to six mm. 
It is then turned upward at an angle with the free margin of 



* Berichi d. Ophthal. Gesselsch. , Heidelberg, 1887, p. 42. 



THE EYELIDS. 241 

the lid about 35°, and a flap about five mm. wide is marked 
out with the knife in the usual crease or fold of the upper lid. 
A narrow, sharp, and pointed scalpel is then thrust under the 
flap at its base, and carried toward its inner end, so as to sepa- 
rate it off without the aid of forceps, scissors, or any other 
instrument. The margins of the wound thus made are brought 
together with four or five sutures, and the flap turned down 
and secured in the gaping intermarginal incision by means of 
four or five sutures between each of its edges and the corre- 
sponding palpebral margin. One suture fastens the free end of 
the flap in the median corner of the wound. The position of 




Fig. 75. 

the cicatrix, just in the fold of the upper eyelid, prevents its 
causing any disfigurement. Were the case one of partial 
trichiasis the intermarginal incision should extend a little 
beyond the point where the abnormal condition ceases. If it 
be the inner half only of the margin of the lid which is affected, 
the intermarginal incision is prolonged toward the nose, and 
the flap so formed that its base lies over the inner canthus. 
The flaps heals in readily, and although it shrinks somewhat, 
secures a wide intermarginal portion. The same drawback in 
connection with the cutaneous hairs on the transplanted flap 
holds good here as in Dianoux's operation. 



242 



DISEASES OF THE EYE. 



Va?t Millingen' s operation * consists in splitting the eyelid, 
as in the Arlt-Jaesche operation, from end to end, sufificiently to 
produce a gap {B, Fig. 76) three mm. in width at the central 
part of the lid, and gradually becoming narrower toward the 
canthi. The gap is kept open by sutures passed through folds 
of skin on the upper lid (ci a a), by means of which also the 
lid is prevented from closing for twenty-four hours at the least. 
As soon as the bleeding has ceased, a strip of mucous mem- 
brane of the same length as that of the lid, and 2 to 2J^ mm. 
in breadth, is cut out with two or three snips of curved 
scissors from the inner surface of the patient's under lip, 




Fig. 76. 

and is placed at once into the gap in the intermarginal space. 
It should then be pressed into position with a pledget of cotton- 
wool steeped in sublimate solution, i : 5000. Sutures are 
superfluous, according to Van Millingen, but I like them, and 
do not find that they do harm. The eyelid is then covered 
over with a piece of lint, on which is spread a thick layer of 
iodoform vaselin, and on this is placed a wad of cotton-wool. 
Both eyes should be bandaged. The sublimate lotion is used 



* Ophthabiiic Review, 1887, p. 309. 



THE EYELIDS. 243 

for disinfecting the eye and lip during, before, and after the 
operation. The bandage should be renewed once in twenty- 
four hours, and the sutures in the upper lid ought not to be 
removed before the second day. 

Van Millingen does not think it advisable to transplant 
small strips of mucous membrane if the trichiasis be partial. 
He regards this condition as only the commencement of com- 
plete trichiasis, and therefore recommends, even in these cases, 
the filling up of the entire length of the intermarginal space 
with a flap of mucous membrane. In cases of shortening of 
the conjunctival surface, in which it has been reduced to ^ of a 
cm., a strip of mucous membrane measuring four mm. in width 
at the center may be transplanted. 

The strip to be transplanted is generally taken from the 
angle of the lip and from the Kne of demarcation between the 
dry and moist surfaces of the Hp. A couple of fine sutures, 
which serve to unite the margins of the w^ound in the lip, 
arrest the bleeding at once, and accelerate union of the part, 
which is generally completed in twenty-four hours. 

The transplanted tissue in this instance being free from 
hairs, the method is not open to the objection referred to 
in Dianoux's and in Vossius' operation, while it is equally 
effectual in permanently providing a good intermarginal space, 
and in thus relieving the condition. 

Entropion (iv, in; rpi-o), to turji), or inversion of the 
eyelid, is due to some organic change in the conjunctiva or 
tarsus, or to spasm of the palpebral portion of the orbicular 
muscle. 

A large proportion of the former class of cases is the result 
of chronic granular ophthalmia, and is most common in the 
upper lid. 

Spastic entropion usually occurs in the under lid. It is 
frequent in old people (senile entropion) from relaxation of 
the skin of the eyelid, and is also produced by the wearing of 



244 DISEASES OF THE EYE. 

a bandage after operations, etc., and by edema of the con- 
junctiva in inflammation of that membrane. 

Treatment. — Organic entropion, in which the tarsus is not 
distorted, can often be corrected by one of the methods 
described for trichiasis and distichiasis. But many of these 
cases are accompanied by, or rather are due to, abnormal 
curvature with hypertrophy of the tarsus. 

In all such cases the operation must include an attack on 
the tarsus itself, or the result will be abortive. Indeed, I 
have little doubt that much of the disappointment experienced 
in the treatment of entropion has been due to imperfect 
appreciation of this fact. 

Streatjield' s operation is as follows : The clamp having 
been applied, an incision is made through the integument of 
the eyelid parallel to its margin, two mm. distant from the 
latter, and extending its whole length. The muscle is dis- 
sected up so as to lay bare the tarsus, and then a wedge- 
shaped piece, two mm. wide and the length of the lid, its ^(\gQ 
pointing toward the inner surface of the lid, is excised from 
the tarsus. A corresponding portion of muscle and skin is 
also removed, and the wound left to heal by granulation. 
The shrinking of the resulting cicatrix causes the marginal 
portion of the tarsus to return to its correct position. 

Snellen's Operation. — Snellen's clamp (very similar to 
Knapp's, which can equally well be used) is applied. About 
three mm. from the margin of the lid, and parallel to it, an 
incision is made through the skin alone, extending the whole 
length of the lid. The orbicular muscle is exposed by dis- 
section of the skin upward, in order to promote retraction of 
the latter, and along the edge of the lower margin of Ihe 
wound a strip, of about two mm. broad, of the orbicular muscle 
is removed, and the tarsus to the same extent exposed to 
view. A wedge-shaped piece corresponding to the exposed 
part of the tarsus is now excised from it with a very sharp 



THE EYELIDS. 



245 



scalpel or Beer's cataract knife, the edge of the wedge point- 
ing toward the conjunctiva, which latter, however, is left intact. 
The hypertrophy of the tarsus, which is always present, 
facilitates this procedure. A silk suture carrying a needle on 
each end having been prepared, one needle is passed from 
within outward through the band of muscle and integument 
left at the margin of the Hd. The second needle is also passed 
from within outward through the upper lip of the tarsal loss 
of substance, and then from within outward through this same 
marginal band, at a distance of about four mm. from the point 
of exit of the first needle. The ends of the suture are now 





Fig. 77. 



Fig. 78. 



tied together, a small bead having first been strung on each 
to prevent it from cutting through the skin. Three such 
sutures are employed. The accompanying woodcuts (Figs. 
77 and yS) make the foregoing description more intelligible. 
Green' s Operation.'^ — An incision is made on the inner sur- 
face of the lid in a line parallel to, and about two mm. distant 
from, the row of openings of the Meibomian ducts. It is 
carried through the conjunctiva and whole thickness of the 
tarsus, and should extend, in cases of complete entropion, from 



* Trans. Aj?ierican OphthaL Soc, Vol. iii, p. 167. 



246 DISEASES OF THE EYE. 

near the inner to the outer canthus. A strip of skin about two 
mm. broad, and tapering to a point at each end, is now excised 
from the lid, the lower margin of the strip being i ^ mm. 
above the line of the eyelashes. The muscle is left intact. 
Fine silk sutures are applied in the following manner by aid of 
a No. 12 glover's needle bent to an arc of about ^ of a 
circle : The needle is first introduced a little to the conjuncti- 
val side of the row of eyelashes, and is brought out just within 
the wound made by the excision of the strip of skin (^A, Fig. 
79) ; it is then drawn through, inserted again in the wound 
near its upper margin, and passed deeply backward and up- 
ward so as to graze the front of the tarsus and emerge through 
the skin a centimeter or more above its point of entrance 
(B, Fig. 79). On tying the two ends of the 
thread together the skin-wound is closed, and 
the loosened lid-margin is at the same time 
everted and brought into a correct position. 
Three sutures generally suffice for the accurate 
adjustment of the lid-margin. In the spaces 
between and beyond the sutures it is often prac- 
ticable and advantageous to turn the eyelashes 
upward against the front of the eyelid, and fix them there by 
means of collodion. The stitches should be removed at latest 
on the day after the operation, the line of suture being then 
strengthened by collodion, or, in case the cilia are very short, 
a few short fibers of cotton are used with the collodion. 

Berlin' s Operation. — Knapp's clamp is applied. The first 
incision lies three mm. above the margin of the lid, extends its 
whole length, and divides it in its entire thickness, including 
the conjunctiva. The skin and muscle at the upper edge of the 
wound are pushed or dissected up so as to expose the tarsus. 
The upper edge of the tarsal incision is now seized at its center 
with a finely-toothed forceps, and an oval piece, with the ad- 
herent conjunctiva, about two to three mm. wide in its widest 




THE EYELIDS. 247- 

part, and in length corresponding with that of the eyelid, is 
excised from it with a fine scalpel. The wound is closed Avith 
three sutures through the skin. If it be thought desirable to 
increase the effect, a skin-flap may be excised from the lid. 
The objection to this operation, that a portion of the mucous 
membrane is removed, is not of importance. Except for an 
occasional granulation forming on the bulbar aspect of the 
wound, I have found the operation free from inconvenience, and 
its result satisfactory and in most instances permanent. 

Spastic entropion, as the result of bandaging, usually dis- 
appears when the use of the bandage is given up ; or, if the 
bandage must be continued, and should the inverted lid cause 
irritation, an epidermic suture at the palpebral margin and 
fastened to the cheek below will give relief 

Senile entropion is, of spastic kinds, the one which most 
commonly demands operative interference. The methods in 
general use for it are : 

TJie excision of a horizontal piece of skin, with a portion of 
the underlying orbital part of the orbicular muscle, so as to 
give rise to sufficient cicatricial contraction to draw the margin 
of the lid outward. 

The application of subcutaneous sutures {Gaillard' s sutJtres). 
— The point of a curved needle carrying a silk suture is 
entered in the center of the lid near its margin, passed deeply 
into the orbicular muscle, brought out at a point some ten 
mm. below, and the suture tied tightly. Two more similar 
sutures, one on either side of the first and about five mm. dis- 
tant from it, are placed, and the resulting suppuration, Avith 
consequent cicatrization, brings the lid into its position. 

Vo)i Graefes Operation. — Three mm. from the margin of 
the lid an incision is made, as in fip;ure 80, through the skin, 
and a triangular skin-flap {^A) excised. The edges B and C 
of the triangle are dissected up a little, and brought together 
by three points of suture, while the horizontal incision is not 



248 



DISEASES OF THE EYE. 




Fig. 80. 



sutured. The size, especially the width, of the triangular flap 
to be excised is proportional to the looseness of the skin. 
When a very marked effect is desired, the flap to be removed 
is given the shape as represented at the right of the figure. I 

have found this proceeding 
extremely satisfactory, and 
its result, as a rule, perma- 
nent. 

All the foregoing and 
other such measures pro- 
duce a good result at the 
time, but are sometimes fol- 
lowed by recurrence of the 
entropion. Hotz * believes 
the cause of this to be that 
the cicatrix, be it dermic 
or dermo-muscular, upon which the result depends has no 
point d' appui ; and consequently, while it may draw the eye- 
lid out, it is just as liable to draw the skin of the cheek up, 
and thus neutralize its desired 
effect. He proposes the follow- 
ing ingenious operation : 

Hotz' s Operation. — A horn 
spatula is inserted under the 
Hd, and then, at four to six 
mm. below the margin of the 
latter, a horizontal incision is 
made through the skin from 
the inner to the outer end of 
the lid. This incision is at the 
boundary between the palpebral 
and orbital pordons of the orbicular muscle and just over the 




y 



Fig 



Klin, Monatsbl. f. Augenheilk., 1880, p. 149. 



THE EYELIDS. 249 

lower margin of the tarsus. An assistant then draws the 
upper edge (a, Fig. 81) of the wound upward with a forceps, 
while the surgeon draws the lower edge (d) downward, in 
this way exposing and stretching the orbicular muscle. A 
few strokes of the knife in the direction of the incision are 
now sufficient to separate the palpebral portion (/) of the 
muscle from the orbital portion (/), and to lay bare the 
lower edge of the tarsus (/), which has a yellowish tendin- 
ous appearance. That part of the palpebral portion of the 
muscle which covered the lower edge of the tarsus, and 
which was drawn up with the palpebral edge of the first inci- 
sion, is now removed with forceps and scissors, to the extent 
of about two mm. in width, through the whole length of the 
lid. All such muscular fibers, also, which may still adhere to 
the lower third of the tarsus must be carefully cleaned off, 
and now the palpebral skin may be brought into union with 
the tarsus. Four sutures are generally applied, about five mm. 
apart. The needle is passed through the palpebral skin, close 
to the margin of the wound (at a). The bare tarsal edge is 
then seized in the forceps, the needle placed perpendicularly on 
it (at d), and carried through it by a short downward curve 
until its point appears (at c) below the tarsus in the tarso-orbital 
fascia (/"). The needle is now passed out through the lower 
edge of the incision (at d), care being taken that none of the 
fibers of the orbital portion of the muscle are included in the 
suture. Upon the suture being tightly closed, the edges of 
the skin wound are drawn into the tarsus, and become ad- 
herent to it. The sutures may be removed about the third 
day. If the first incision be placed too far from the margin 
of the lid there will be no result, as the traction upon the 
palpebral skin will be too slight. If the incision be placed 
too close to the margin, the traction may be so great as to 
interfere with the union of the skin and tarsus. In this opera- 
tion the tarsus affords the fulcrum, which. Hotz thinks, is want- 



250 DISEASES OF THE EYE. 

ing in other methods. The tarsus of the lower hd is some- 
times very httle developed, and then I find the result of the 
operation may be disappointing. 

Ectropion, or Eversion of the Eyelid. — Of this there 
are two chief kinds : i. Muscular, or spastic. 2. Cicatricial. 

Muscular ectropion may be caused by edema of the con- 
junctiva, which everts the edge of the eyelid, and this eversion 
is increased and encouraged by spasm of the palpebral portion 
of the orbicular muscle, so that the name palpebral paraphi- 
mosis has been given to the condition. In the recent stage it 
may generally be remedied by a properly applied bandage, 
combined with the suitable conjunctival measures. In chronic 
cases Snellen's sutures {vide infra) may be required. 

Muscular ectropion is often seen in old people, and is then 
given the name of senile ectropion. Here it is due to atrophy 
of the palpebral portion of the orbicularis and relaxation of 
the skin of the face. When these have resulted in slight 
eversion of the inferior punctum, a flowing of tears is pro- 
duced, causing excoriations of the skin and edge of the lid, 
which then, in their turn, increase the tendency to ectropion. 
If the condition be not extreme, with secondary changes in 
the conjunctiva, slitting up of the canaliculus, with the use of 
a boracic ointment for the lids and mild astringents for the 
conjunctiva, will give much relief. In pronounced cases a 
more active treatment of the conjunctiva, and the performance 
of tarsorrhaphy, the latter preceded by the application of 
Snellen's sutures, are demanded. Muscular ectropion is 
also caused by paralysis of the orbicular muscle. 

Snelleii s Sutler es. — A silk ligature is threaded at either end 
with a needle of moderate size and curve. The point of one 
of these needles is passed into the most prominent point of 
the exposed and everted conjunctiva, and brought out through 
the skin two cm. below the edge of the lower lid. The other 
needle is entered in the same way five mm. from the first, and 



THE EYELIDS. 251 

made to take a nearly parallel course, the points of exit on the 
cheek being one cm. apart. Equal traction is applied to each 
end of the suture, while the lid is assisted into its place by the 
fino-er. The suture is tied on the cheek, a small roll of stick- 
ing-plaster having been inserted under it to protect the skin 
from being cut. Two, or even three, such sutures may be 
required. 

Ai^gyll-Robertsoii s operation * has been designed for those 
cases of ectropion which result from long-continued chronic 
inflammation of the conjunctiva of the lower lid. He thinks 
the difficulty in severe cases of this kind depends upon the 
abnormal curvature, which is gradually acquired by the tarsus. 
The following is his description of the operation, from which 
he has obtained satisfactory results : 

The materials required are : 

1 . A piece of thin sheet-lead about one inch long and y^ of 
an inch broad, rounded at its extremities, and with its cut 
margins smoothed. This piece of lead must be bent with the 
fingers to a curvature corresponding to that of the eyeball. 

2. A waxed silk ligature about 15 inches long, to either 
extremity of which a long, moderately curved needle is 
attached. 

3. A piece of fine india-rubber tubing of the thickness of a 
fine drainage-tube. 

The operation is performed by perforating the whole thick- 
ness of the lid with one of the needles, at a point (b, Fig. 
82) one line from its ciliary margin, and y^ of an inch to 
the outer side of the center of the lid. The needle having 
been drawn through (at a), is passed directly downward over 
the conjunctival surface of the lid till it meets the fold of 
conjunctiva reflected from the lid on to the globe, through 



^Edinburgh Clinical and Pathological Journal, December, 1883; and Ophthal. 
Rev.f February, 1 884. 



252 



DISEASES OF THE EYE. 



which the needle is thrust — the point being directed sh'ghtly 
forward — and pushed steadily downward under the skin of 
the cheek, until a point (d) is reached about one inch or \y^ 
inches below the edge of the lid, when the needle is caused to 
emerge, and the ligature is drawn through. The other needle 
is, in like manner, thrust through the edge of the lid at a 
corresponding point {b') y^ of an inch to the inner side of 
the middle of the lid, then passed over the conjunctival surface 
of the lid, through the oculo-palpebral fold of conjunctiva, 




Fig. 82. 



and downward under the skin, till the point emerges at a spot 
{d') y^ of an inch outward from the point of exit of the first 
needle (d^. The ligature is kept slack, or is slackened so as 
to permit of the piece of lead being introduced under the loops 
of the ligature that pass over the conjunctival surface of the 
lid, and of the piece of india-rubber tubing {c) being slipped 
under the loop at the edge of the lid (between b and b'). The 
free ends of the ligature are now drawn tight, and tied moder- 



THE EYELIDS. 253 

ately tight over a lower part of the india-rubber tube ; 
the excess of india-rubber tube is cut off, about 3_^ of an 
inch beyond the ligature, and the operation is complete. 

The result of the procedure is that the edge of the lid is 
made to revolve inward over the upper edge of the piece of 
lead, while the tarsus is caused to mold itself to the curve of 
the lead, and the eyelid at once occupies its normal position. 
A certain amount of redness and edema of the lid follows the 
operation, and suppuration occurs in the track of the ligature ; 
but as the india-rubbia tube \-ields somewhat to the tension 
on the ligature, the resulting irritation is moderate, so that the 
apparatus need not be removed for five, six, or seven days, by 
which time the tarsus has become pretty well fixed in its new 
curvature. A slight relapse may occur when the apparatus is 
removed, but this is readily am.enable to treatment by astrin- 
gent applications. 

The suppuration occurring in the tracks of the ligature 
leads to cicatricial formation, which appears ta impart a degree 
of rigidity to the lid that helps to keep the latter in its new 
position. 

KennetJi Scoffs Operatio7i.^ — The external canthus and 
tissues beyond are thoroughly divided by a pair of strong 
scissors ; the lower eyelid, which is usually the affected one, 
is then seized and its margin stretched sufficiently outward, 
parallel to the border of the other lid, so as to restore the 
palpebral aperture to its proper appearance ; the portion of 
e}'elid margin thus made to extend beyond the site of the 
external canthus is removed, along with its contained eye- 
lashes, by shcing it with a sharp knife. The upper and lower 
eyelids are then brought together, so that the original outer 
extremity of the one approximates exactly to the new extrem- 
ity of the other eyelid. They are secured in this position by 

"^ Brit. Med. Jour., September, 1S96. 



254 



DISEASES OF THE EYE. 



passing a silver wire suture vertically downward through the 
substance of the upper lid, continuing it out through that of 
the lower one, and then twisting the ends firmly together. 
Two of these retaining stitches may be introduced close 
together if necessary. The edges of divided skin, along with 
the deeper muscular tissues, including that part which recently 
formed the outer end of the affected eyelid, are simply stitched 
together with a continuous fine silk suture. 

No dressing other than a repeated dusting with dermatol 
need be used. The silk stitches may be removed in six days' 
time, the silver ones being left in for five or six days longer. Dr. 




Fig. 83. 



Fig. 84. 



Scott states there is never any puckering apparent beyond 
the newly-formed canthus, and the small linear cicatrix is lost 
amongst the other lines often found there. 

Cicatricial ectropion is caused by scars from wounds or 
burns, or from caries of the orbit, and can only be relieved by 
operation. 

WJiarton Jones' operation is as follows : The cicatrix is cir- 
cumscribed by a V-shaped incision (Fig. 83), and the skin 
made thoroughly movable in its neighborhood. The edges 
of the wound are now brought together so as to form a Y 
(Fig. 84). 



THE EYELIDS. 



255 



-nC 



Arlfs operation for cases due to caries of the margin of the 
orbit : If the cicatrix be situated at c (Fig. 85), the incisions 
at a b and b c are made through the skin and muscle, so that 
an acute, or at most a rio"ht, ang-le is formed at b. The mar- 
gin of the lid from r to d \i excised. The cicatrix is com- 
pletely undermined, and the triangle dissected up from /; to 
the margin of the tarsus, so that the lid can be readih' put into 
its position, and the edge c b of the flap united to d c. The 
size of the exposed surface on the cheek can, according to 
Arlt. be diminished b}- drawing its edges together after the 
manner of a harelip, but possibly the transplantation of a 
piece of skin from the arm to fill 
the gap might be a better plan. 

The foregoing and similar opera- 
tions are difficult or impossible in 
many cases where there has been 
great destruction of the skin of the 
eyelids and surrounding parts by 
burns, ulcers, etc., and at best the 
deformity is liable to recur. Trans- 
plantation of skin from different 
parts is in these cases a more promising proceeding. A 
description of the method is given in the next paragraph but 
one. 

Ankyloblepharon {ay/M-q, a string ; ^U(papuv, an eyelid) is 
a uniting of the upper and lower eyelids along their margins. 
It may be partial or complete, and often goes with symble- 
pharon. Like the latter, it is usualh* caused by burns and 
ulcers. 

The condition can only be relieved b}- operation, of which 
the result is often unsatisfactory, owing to the difficult}' of 
preventing reunion taking place. To avert this it is always 
necessary to cover the wounded surface with conjunctiva or 
skin. 




b' 



Fig. 8v 



256 DISEASES OF THE EYE. 

The Restoration of an Eyelid. — It is an extremely rare 
event for the whole substance of one or both eyelids to be 
destroyed by lupus, or other ulceration, or by accidents, which 
do not at the same time injure the eyeball seriously. In this 
rare event the eyeball, especially if the upper lid be destroyed, 
is exposed ; the patient is subject to extreme discomfort, and, 
owing to ulceration of the cornea, the eye is ultimately lost. 

The formation of an eyelid from the skin of the forehead 
or cheek in these cases is a most disappointing proceeding, and 
one the description of which does not, I consider, come within 
the scope of this book. Indeed, my own feeling in such a 
case would be to recommend enucleation of the eyeball, pro- 
vided the fellow eye were good, rather than to propose a plas- 
tic operation which, at the best, would give but an imperfect 
result. 

But, fortunately, the class of cases with which we commonly 
meet are essentially different in their nature ; for in them the 
whole thickness of the eyelid is not destroyed. They are 
usually the result of burns (epileptics and children falling in 
the fire) and scalds, which only destroy the integument of 
one or both eyelids. A granulating surface replaces the skin, 
and when healing commences the shrinking process draws the 
free margin of the upper eyelid up toward the eyebrow and 
that of the lower lid down toward the cheek, while the con- 
junctival surface of the eyelids becomes everted and the cor- 
nea exposed, as the eyelids cannot now be closed. We have 
a satisfactory method for dealing with these cases. 

In the first place, the eyelid — let us suppose it to be the 
upper eyelid — is dissected down into its place to the utmost 
limit, so that the most extensive raw surface possible may be 
obtained. The margin of the lid is now fastened to the cheek 
with three points of suture. A portion of skin one-third 
larger (to allow for shrinkage) than the raw surface of the 
eyelid, is then taken from the inside of the arm, and after 



THE EYELIDS. 257 

being freed of its subcutaneous fat, is laid upon the raw surface 
and fastened to it by a large number of fine sutures around 
the margin. A non-irritating antiseptic dressing is applied, 
and the graft usually heals on in the course of a few days. 
This method of grafting was introduced by Wolfe and Lefort, 
and I have employed it many times with most satisfactoiy re- 
sults. 

It is most important to preserve and utilize any part of the 
eyelid which remains, especially its ciliary border with the 
eyelashes. 

The flap sometimes becomes separated from the wounded 
surface by oozing of blood or serum from the wound, and 
then sloughs. To prevent this, Wickerkiewicz has employed 
secondary transplantation with satisfactory results. The flap 
is applied to the wounded surface from two to five days after 
the latter has been prepared, while during the interval the 
wounded surface has been protected with moist antiseptic 
dressings. He states that union by first intention occurs 
readily by this method. 

Injuries of the Eyelids. — All kinds of injuries of the eye- 
lids (contusions, incisions, burns, etc.) are common. 

In consequence of the looseness of the integument, edema 
and ecchymosis, one or both, are often seen in a marked de- 
gree as the result even of slight injuries. 

Owing to the direction of the fibers of the orbicularis, an 
incised wound of the eyeUd, if in the vertical direction, will 
gape, while a similar wound in the horizontal direction will 
not do so. Hence the scar left after the former wound is 
apt to be very visible, but that after the latter may be almost 
imperceptible. If the eyelid be divided vertically in its entire 
thickness, unless union by first intention can be obtained, a 
deep furrow is left in the eyelid, and, perhaps, at its margin 
an unsightly coloboma. 

Emphysema of the eyelids is sometimes seen after a blow 
22 



258 DISEASES OF THE EYE. 

on the eye, and is a sign of fracture of the orbit, with a com- 
munication between the subcutaneous connective tissue of the 
eyehds and the nose, the ethmoid sinus, the frontal sinus, or 
the antrum of Highmore. An emphysematous lid is swollen, 
and soft and crepitating to the touch. 

Ecchymosis of the lower lid, usually with ecchymosis of 
the lower conjunctiva, after falls or blows on the head, is a 
sign of fracture of the base of the skull, the blood making its 
way along the floor of the orbit. 

Simple ecchymosis of the eyelids from blows, commonly 
known as "black eye," never gives rise to further compli- 
cation. It requires some fourteen days or more, according to 
the quantity of blood extra vasated, before the eye recovers its 
normal appearance. 

Treatment. — Injuries of the eyelids, of whatever kind, are 
of course treated upon general surgical principles. Incised 
wounds should be carefully and neatly drawn together with 
sutures as soon after the injury as possible, and with antiseptic 
precautions. Emphysema may be assisted in its absorption 
by the application of a rather tight bandage, and directions 
should be given to the patient to blow his nose as gently as 
possible, so as to avoid recurrence of the emphysema. 

Epicanthus is a congenital deformity, usually binocular, 
which, in the most pronounced cases, consists in partial 
paralysis of the levator palpebrae (ptosis) and of the rectus 
superior, with a narrow palpebral fissure, and a fold of in- 
tegument at the inner canthus concealing the caruncle from 
view, and giving the appearance of great breadth to the 
bridge of the nose. The term is also used for cases in which 
the integumental fold at the inner canthus is the only abnormal 
condition, and this deformity can be somewhat diminished by 
the removal of an oval piece of skin from the bridge of the 
nose, its long axis being vertical and its width var}ing accord- 
ing to the effect required. When the margins of the wound 



THE EYELIDS. 259 

are brought together, the abnormal folds are diminished in 
width. 

Congenital coloboma of the upper lid, sometimes associated 
with a dermoid cyst of the limbus of the cornea corresponding 
to the cleft in the lid, and even congenital absence of the eye- 
lids have been occasionally observed. 



CHAPTER VIIL 

DISEASES OF THE LACRIMAL^ APPARATUS. 

Malposition of the Punctum Lacrimale.f — Inversion of 
the punctum accompanies entropion of the lower eyelid, 
while eversion of it is present with ectropion of the lid. A 
slight eversion, quite sufficient to cause epiphora, may exist 
without any marked ectropion of the lid, and it is these 
cases which more properly belong to this chapter. They are 
the result generally of some chronic, although it may be 
slight, skin affection of the lower lid, which draws the inner 
end of the latter a little away from the eyeball. 

The prominent symptom of this and of all the following 
lacrimal affections is epiphora (^^ntipopd daxputov^ a sudden burst 
of tears')^ a flowing of tears over the cheek. 

Stenosis and Complete Occlusion of the Punctum 
Lacrimale. — Either of these conditions may result from con- 
junctivitis or from marginal blepharitis, although they may 
not appear for a length of time after those affections have 
passed away, and the original affection may have been so 
slight as to have escaped the observation of the patient. In 
stenosis, the size of the punctum may become so extremely 
minute that even the normal flow of tears is too great to 
make its way through it. Complete occlusion is probably 
only a more advanced stage of stenosis. 

* Lac7-iina, a tear. 

f In this chapter, and elsewhere in the book, the terms punctum lacrimale 
and canaliculus refer to the inferior passage, unless it be otherwise expressly- 
stated. 

260 



A 



THE LACRIMAL APPARATUS. 261 

T/ie treatment in cases of eversion of the punctum, of 
stenosis, and of complete occlusion is similar — namely, 
the opening up of the punctum, and its conversion into 
a slit. This is done with a Weber's knife (Fig. 86), 
the probe-point of which is passed into the punctum 
in cases of eversion, forced into the small opening in 
cases of stenosis, or forced through the usually thin 
covering of the punctum in cases of occlusion. In 
doing this, the lower lid should be stretched tightly 
by a finger of the surgeon's left hand placed near the 
external canthus. The edge of the knife being now 
directed toward the eyeball the instrument is pushed 
on a little into the canaliculus, until two mm. of the 
latter has been opened up, and it is then withdrawn. 
If the edge of the knife be directed outward in this 
proceeding, the incision comes to lie on the outer edge 
of the intermarginal portion of the lid, and not in 
contact with the eyeball ; consequently the tears are 
not carried away, and the disfigurement produced is 
considerable. A slitting up of the whole or the 
greater part of the canaliculus in these cases is un- 
necessary, and interferes with the physiologic action 
of the tear passage. For two or three days after the 
little operation it is necessary to pass a probe along 
the portion of the canaliculus which has been slit up, 
to prevent union taking place. 

Obstruction of the Canaliculus. — The canaliculus 
may be diminished in its caliber, or entirely closed, 
by contraction, the result of inflammation which had 
extended to it from the conjunctival sac. It is not 
possible to diagnose the presence of either of these 
conditions, which may be associated with stenosis or 
occlusion of the punctum lacrimale, except by the introduc- 
tion of a very fine probe into the canaliculus. The passage 



Fig. 86. 



262 DISEASES OF THE EYE. 

may also be obstructed by an eyelash, a chalky deposit, or 
a mass of leptothrix. 

Treatment. — Where there is merely diminution in the caliber 
of the passage, the introduction of probes, increasing in size, 
is frequently sufficient to effect a cure. If dilatation fail, re- 
course must be had to slitting up the canaliculus ; but if it 
can possibly be avoided — that is, if a less extended opening 
will answer — the passage should not be slit up in its entire 
length. At least three mm. of its median end ought to be left 
intact, as otherwise regurgitation of tears from the lacrimal 
sac is liable to trouble the patient ever afterward. If the 
canaliculus be completely closed by adhesions, so that a fine 
probe cannot be pushed through it, it becomes necessary to 
rip it up with the point of any small knife, following the 
known course of the passage from the outside. If the canali- 
culus be closed as far as the opening into the sac, or if only at 
that point, the obstruction must be pierced with the point of a 
fine knife. A great difficulty in all these cases is to keep the 
passage patent when once formed. A plan which affords tol- 
erable certainty of this is the frequent passage of probes into 
the sac until the tendency to closure seems to have ceased ; 
but even under favorable conditions, recurrences of the closure 
are apt to occur. In order to cure this condition, and in the 
hope of doing so permanently. Dr. W. E. Steavenson and Mr. 
Walter Jessop * have employed electrolysis, which they apply 
to the canaliculus by means of a platinum probe fitted in a 
handle and connected with the negative pole of a Stohrer's 
battery. A flat electrode connected with the positive pole is 
placed on the back of the neck. A current of two to four 
milliamperes is sufficient, and the operation lasts thirty 
seconds. By this procedure the canaliculus is rendered wide 
enough ; but time has yet to show whether recurrence of 



Brit. Med. Journal, December 24, 1887. 



THE LACRIMAL APPARATUS. 263 

the stricture is less frequent than after treatment by other 
methods. 

Stricture of the nasal duct is usually the result of swelling 
of its mucous membrane in catarrhal attacks, or of mem- 
branous or cicatricial contraction resulting from long-con- 
tinued catarrh. It also occurs in consequence of disease of 
the bones of the nose ; e. g., in syphilis, acquired or congeni- 
tal, and from blows which fracture the bridge of the nose. 

Trcaimcnt. — Bony stricture may be regarded as incurable. 
Stricture due to inflammatory swelling of the mucous mem- 
brane, also membranous or cicatricial strictures, are best 
treated by means of probes in the manner proposed by Sir 
William Bowman. The inferior canaliculus is slit up to a 
slight extent so as to admit the point of one of Bowman's 
smallest probes, which is given a curve to suit that of the 
nasal duct. With the fingers of the left hand the surgeon 
stretches the lower lid, and entering the probe into the 
canaliculus, pushes it gently along its floor until the point 
reaches the lacrimal bone forming the posterior wall of the 
sac. The point being kept pressed against this bone, the 
direction of the probe is now altered by carrying its free 
end upward toward the bridge of the nose until its other 
point in the lacrimal sac is directed toward, or aimed at, 
the sulcus between the ala of the nose and the cheek. The 
probe, then, is in a position corresponding to the prolonged 
axis of the nasal duct, down which it is pushed with a slow 
and gentle motion. Any obstacles met with on the way are 
overcome, if possible, by an increase of the pressure ; but if 
at any part of the proceeding much difficulty be encountered, 
rather than that any violence be used, all further manipulation 
should be postponed to another day, and it will often be found 
that at the second or third visit the probe is passed with com- 
parative ease. Thicker probes are gradually introduced at 
successive sittings until the largest size has been reached. 



264 DISEASES OF THE EYE. 

The most common seats for stricture of the nasal duct are 
at its entrance into the sac, where it is narrowest, and at its 
lower end, where it is most exposed to catarrhal processes in 
the nostril. 

Where there is reason to think that the stricture is due to 
chronic catarrhal swelling of the lining mucous membrane of 
the duct, astringent injections into the canal, in addition to the 
probing, are of use. 

Otto Becker used very fine probes, which he passed by the 
upper canaliculus. Weber's probes are conic, and of very 
large caliber at their thickest part. Their inventor passes 
them by the superior canaliculus, but many other surgeons 
pass them by the lower. I do not employ these probes, be- 
cause, when passed into the nasal duct, their thickest part, which 
is three to four mm. in diameter, corresponds with the upper 
end of the duct, which is its narrowest part, being only three 
mm. in diameter ; consequently the probe becomes more or 
less impacted at this place at each operation, and is apt 
ultimately to give rise there to hypertrophy of the periosteum, 
and finally to stricture ; so that, while the immediate effect of 
their use is good, the ultimate result is often the reverse. 
W^hen used by the inferior canaliculus their size makes it 
necessary to slit that passage in its entire length, and the 
entrance of the passage into the sac must be enormously 
dilated by so large an instrument, both of which circumstances 
are most undesirable. 

To prevent closure of the duct when once made free, Dr. 
Arthur Benson (Dublin) advocates the use of leaden styles, 
removable by the patient. He first divides the canaliculus (by 
preference the upper one), and dilates the stricture with probes 
in the ordinary way, and then introduces into the duct a piece 
of leaden wire 1.5 mm. to 2 mm. in diameter, cut to length, 
and smoothed off at the ends. The style is at first removed 
daily, and the duct syringed, until any existing inflammation 



THE LACRIMAL APPARATUS. 265 

and discharge have almost ceased. The intervals are then 
increased, and as soon as practicable the patient is taught to 
remove the style and to replace it himself. When he is able 
to do this easily, he is directed to leave the style out for some 
hours each day, and finally to wear it only at night. 

Stilling has proposed an operation, which he calls strictur- 
otomy, for the cure of membranous obstructions in the duct. 
Having sht up the canaliculus, and ascertained with a probe 
the position of the stricture, Stilling passes his knife, with the 
cutting edge directed forward, down the duct and through 
the stricture ; he then withdraws it a little, turns the edge 
in another direction, and pushes it again through the stricture, 
and performs this manceuver a third time before removing the 
knife. On subsequent days large probes are passed. This 
method has never gained much popularity. 

Very obstinate strictures can sometimes be freed by 
electrolysis. 

The most favorable cases of stricture for cure are those due 
to inflammatory swelling of the mucous membrane, and next 
in order come those caused by membranous or cicatricial 
contraction, while those due to bony obstructions must, as 
already stated, be regarded as incurable. 

Now and then cases of persistent lacrimation will be met 
with in which the nasal duct and the rest of the lacrimal 
apparatus are in perfect order. These are often due to a 
catarrhal affection of the nasal mucous membrane, slightly 
involving the very lowest extremity of the nasal duct. Here 
applications directed toward relief of the nasal affection are 
indicated. 

Blennorrhea of the lacrimal sac is commonly caused, 
in the first instance, by stricture of the nasal duct. In con- 
sequence of this stricture the tears and the normal mucous 
secretion of the lining membrane of the sac are retained there, 
and offer favorable conditions for the development of the 



266 DISEASES OF THE EYE. 

microorganisms, which are constantly present on the surface 
of the eye, and are carried into the lacrimal sac by the tears. 
These decomposing contents of the sac set up inflammation of 
its mucous membrane, with discharge of a mucopurulent nature. 

But one not seldom comes across cases of lacrimal blen- 
norrhea where, upon examination, no stricture of the nasal 
duct is found ; yet in many of these cases there has been 
a stricture due merely to catarrhal swelling of the lining 
membrane of the duct, which swelling has subsided in the 
course of time without treatment, and the duct has then 
again become free, while still the lacrimal blennorrhea to 
which the stricture gave rise continues. It is very probable, 
however, that lacrimal blennorrhea may occasionally come 
on where there has never been a stricture of the nasal duct, 
and merely as an extension of catarrh from the nostrils, 
especially in cases of ozena, or as an extension of catarrh 
from the conjunctiva. 

Symptoms. — The patients usually complain of nothing more 
than epiphora. Those who are more observant of themselves 
may have noticed a swelling, which we call a lacrimal tumor or 
mucocele, in the region of the lacrimal sac ; and also that the 
conjunctival sac, especially when the swelling is pressed upon, 
becomes now and then more or less filled with a somewhat 
thick and opaque discharge, which obscures the sight until 
wiped away. Occasionally there is no lacrimal tumor, for the 
contents of the sac may not be copious enough to bulge it out. 

In order to ascertain in each case of epiphora whether or 
not lacrimal blennorrhea be present, the surgeon presses with 
his finger over the lacrimal sac, when, if there be blennorrhea, 
the discharge will be evacuated through the puncta into the 
conjunctival sac. In those cases in which there is no longer 
a stricture of the nasal duct the discharge may pass downward 
into the nose, and the patient will feel it in his nostril, out of 
which he can blow it. 



THE LACRIMAL APPARATUS. 267 

Conjunctivitis must sometimes be regarded, not as the cause, 
but rather as the effect of a lacrimal blennorrhea, by reason of 
the decomposing discharge from the sac making its way into 
the conjunctival sac. Blepharitis, too, is seen as a further 
result of irritation from the discharge in old-standing cases. 

Treatment. — It is important, in the first place, to ascertain 
whether there be a stricture of the nasal duct, and for this 
purpose water should be injected, by means of an Anel's 
syringe, through the canaliculus into the duct. If the fluid 
make its way freely into the nose or pharynx, it may be taken 
for granted that the nasal duct is not obstructed ; but if, in- 
stead of passing through — or only under high pressure — it 
distends the lacrimal tumor to a greater size, a stricture may 
be assumed. If stricture of the nasal duct be present it must 
be relieved, or all other measures will prove futile. Should 
there be no stricture, and also before and after any existing 
stricture has been freed, the treatment consists in the very 
frequent pressing out of the contents of the sac by the patient, 
so that no distension of it may occur ; and in this manoeuver 
he should endeavor to cause the discharge to pass down the 
nose rather than into the eye ; while the surgeon, having, if 
necessary, dilated the canaliculus, injects astringent solutions 
(sulphate of zinc, nitrate of silver, alum, sulphate of copper) into 
the sac daily, to relieve the catarrh. 

The caustic treatment, recommended further on for acute 
dacryocystitis, is often of the greatest benefit in these chronic 
cases. Any existing conjunctivitis or nasal catarrh should be 
treated. 

Acute Dacryocystitis {pay.pbu}, to weep ; -/.ugtic^ a bladder^. — 
Acute inflammation of the lacrimal sac most usually comes on 
when chronic lacrimal blennorrhea is already present. Caries 
of the nasal bones may cause it, and it occurs idiopathically, 
probably as the result of exposure to cold. 

The region of the lacrimal sac and the surrounding integu- 



268 DISEASES OF THE EYE. 

ment become swollen, tense, and red, and these conditions 
often spread to the lids, giving an appearance which may be 
readily mistaken for erysipelas ; but the history of the case, 
showing the previous existence of lacrimal obstruction, etc., 
will assist the diagnosis. Great pain accompanies the inflam- 
matory process. Gradually the region corresponding to the 
lacrimal sac becomes the most prominent one of the swelling, 
and the abscess, pointing there, opens. When the pus has 
been discharged the inflammation subsides, and the opening 
through the skin may either close, the parts resuming their 
normal functions, or the opening may remain as a permanent 
fistula. 

The difference between chronic blennorrhea of the lacrimal 
sac and acute dacryocystitis, besides the fact that one is a chronic 
and the other an acute inflammatory process, is that the 
former process is confined to the mucous membrane of the sac, 
while in the latter the submucous tissue is involved, with phleg- 
monous inflammation as the result. 

Treatment. — In the early stages poultices and purgatives 
should be employed. As soon as palpation of the sac indicates 
the presence of pus it must be evacuated. This can be effected 
either through the canaliculus, by opening it up to its entrance 
into the sac, or by an incision through the integument over the 
sac. The latter is the method I prefer, as it admits of free 
access to the interior of the sac. The day afterward the walls 
of the sac are to be freely touched with solid mitigated nitrate 
of silver ; or a plug of cotton-wool soaked in a strong solu- 
tion of nitrate of silver may be inserted into its cavity, and 
left there for some hours ; or various astringent solutions may 
be injected into the sac. The aim of the treatment, whatever 
it may be, is to secure a rapid return of the mucous membrane 
to its normal condition. If stricture of the nasal duct be pres- 
ent, it must be \x^dXitdi pari pas S7i. By these means the dis- 
charge from the sac is arrested, and the external opening closes. 



THE LACRIMAL APPARATUS. 269 

If a fistula should form it may be induced to close, in many 
cases, by simply freeing an existing stricture of the nasal duct ; 
or it may be necessary to pare its edges, and bring them 
together by sutures ; or, especially if there be a long fistulous 
passage, the galvano-cautery, in the form of a platinum wire, 
can be applied with advantage. 

Obliteration of the sac may have to be brought about in 
some very chronic cases, where repeated attacks of acute in- 
flammation and fistula occur, or where there is constant dis- 
charge, and disease of bone, and when all other methods have 
failed to relieve the patient. This can be done by the applica- 
tion of a galvano-cautery to the lining membrane of the sac, 
or b\' dissecting it out. But I must say that, in my experi- 
ence, obliteration of the lacrimal sac is one of the most difficult 
undertakings in ophthalmic surgery. 

Removal of the lacrimal gland, or excision of the palpebral 
portion (de Wecker) is sometimes performed for the relief of 
incurable epiphora. The palpebral portion can be removed 
from the conjunctival surface. It can be seen in the upper cul- 
desac by separating the eyelids widely at the outer canthus, 
while the patient looks well down and to the nasal side. 

Dacryoadenitis (^daxpuw, to weep ; ddrj'^, a gland), or inflam- 
mation of the lacrimal gland, occurs both in an acute and 
in a chronic form, but is extremely rare in either. I have seen 
one case of acute purulent dacryoadenitis, but no instance of 
the chronic affection. Swelling and hyperemia over the gland 
and of the whole lid, with chemosis of the conjunctiva and 
much local pain, increased on pressure, are the most marked 
symptoms of acute dacryoadenitis. When suppuration has 
taken place, the abscess may open into the conjunctiva, as it 
did in my patient, or through the skin. In the latter case it 
is liable to leave a fistula behind it, and indeed the chronic 
form may also, it is said, lead to fistula. 

Numerous cases of chronic enlargement of both lacrimal 



270 DISEASES OF THE EYE. 

glands have been recorded. Good results have been obtained 
by administration of potassium iodid or mercury in some 
cases. 

Ti'eatjneiit in the early stages consists in poultices and pur- 
gatives. When pus has formed the abscess may be opened 
through the skin or from the conjunctiva. 

Hypertrophy of the lacrimal gland is also of rare occur- 
rence. It may attain such dimensions as to push the eyeball 
out of its position. It can only be dealt with by : 

Extirpatioji of the Lacrimal Gland. — This is performed by 
making an incision through the integument under the outer 
third of the orbital margin ; the fascia under this is dissected 
up, the gland drawn out with a hook, and dissected out with 
a scalpel. 

Tumors of the Lacrimal Gland. — See chapter xix. 



CHAPTER IX. 

DISEASES OF THE SCLEROTIC. 

Inflammation of the sclerotic is not a common disease, 
although the diagnosis " scleritis " is often made by inexperi- 
enced persons, every redness of the white of the eye being 
taken for inflammation of the sclerotic. Beginners are warned 
against this error. Iritis, cyclitis, and conjunctivitis, as well 
as scleritis, cause redness of the white of the eye. 

The diagnosis from conjunctivitis is easily made by observ- 
ing whether the conjunctival vessels can be moved over the 
affected part or not ; while in iritis and cyclitis the ciliary in- 
jection is confined to the part immediately surrounding the 
cornea. Moreover, in iritis the appearance of the iris itself is 
conclusive ; and in scleritis, as will just now be seen, the 
appearances are characteristic. 

Scleritis attacks only that part of the sclerotic which is an- 
terior to the equator of the eyeball, and is either superficial or 
deep. The superficial form is known as episcleritis. Yet it 
is not always possible to distinguish between these two forms 
in a given case, as the appearances in the early stages are very 
similar. They are probably only different degrees of the 
same disease. But the necessity of admitting the existence of 
two forms depends upon the different course they each take ; 
the superficial form being a relatively harmless disease, while 
the deep form entails serious consequences. 

Episcleritis appears as a circumscribed purplish, rather 
than red, spot close to, or two to three mm. removed from, the 
corneal margin. It is often unattended by pain, unless when 

271 



272 DISEASES OF THE EYE. 

the eye is exposed to irritating causes, and need not be ele- 
vated above the level of the sclerotic ; but in severe cases 
there is a decided node at the affected place, with more or less 
pronounced pain, which is increased on pressure. All the 
symptoms disappear in the course of a few weeks, and reap- 
pear at an adjoining place ; and in this way, in time, the whole 
circumference of the sclerotic will have been attacked. The 
duration of the affection is usually long ; and in those in- 
stances where the entire sclerotic becomes affected by degrees 
the process may last for years, on and off Both eyes are 
often affected. The disease is liable to leave behind it a dusky 
discoloration of the sclerotic where each node was seated, but 
otherwise no harm to the eye ensues. But the patient should 
be made acquainted with the tedious nature of the affection. 
Very mild attacks of episcleritis will be met with, which pass 
away in a few days and do not recur. 

Caitses. — The affection is often of rheumatic origin. It 
occurs sometimes in persons of scrofulous or syphilitic consti- 
tution ; and it is more frequent in senior adults than in children 
or young people, and more commonly attacks women than 
men. 

Treatment. — No irritant should be applied to the eye. 
Local treatment should be confined to warm fomentations and 
protection. In addition to these massage should be used, if 
there be not too great tenderness on pressure. Leeching at 
the external canthus is of use when the pain is severe. As re- 
gards internal remedies, where a syphilitic taint is present 
mercury should be employed ; if struma, cod-liver oil, maltine, 
etc. ; or if, as is most frequently the case, the rheumatic taint 
be the source of the evil, large doses of salicylate of sodium, 
say 20 grains four times a day, will often be found to act well. 
Salicylate of lithium is recommended in preference to the 
sodium salt by some. lodid of potassium and hypodermic 
injections of pilocarpin are useful remedies in some cases of 



THE SCLEROTIC. 273 

this obstinate disease. Subconjunctival injections of corrosive 
sublimate or of salicylate of soda have also been recently tried. 

Periodic Transient Episcleritis (Fuchs), or Hot Eye 
(Hutchinson). — This affection has been long known by the 
name given to it by Mr. Hutchinson,* and it has recently been 
described by Fuchs f under the title episcleritis periodica 
fugax. It is characterized by frequently recurring attacks of 
inflammation of the episcleral connective tissue, giving rise to 
a vascular injection of a violet hue, but without any catarrhal 
or other secretion, or any hard infiltration, as in episcleritis of 
the usual type. It rarely attacks the whole sclerotic at one 
time, but is commonly confined to a quadrant or more, and 
wanders from one place to another. When the attack sub- 
sides there is no stain left behind. The attack may be con- 
fined to one eye, or both may be affected, or it may go from 
one eye to the other. Pain, watering of the eye, and photo- 
phobia are present in varying degrees. Sometimes there is 
swelling of the eyelids. Occasionally the iris and ciliary body 
become inflamed, and also the retrobulbar tissue, with result- 
ing exophthalmos. The attacks last from one or two days to 
several weeks, and may recur once or twice a year and with 
intervals of only two or three weeks. Patients are usually 
liable to the disease for several years of their life. It attacks 
adults of middle age for the most part. Mr. Hutchinson 
assigns gout as the cause ; but Fuchs has not been able to find 
any signs of that diathesis in his patients. Rheumatism and 
malaria seem sometimes to produce it, and in many instances 
no cause can be ascertained. 

Treatment. — The long continuance of most of the cases 
shows that treatment has but little influence over the disease. 
Quinin and salicylate of soda internally are the remedies 

* Bowman Lecture, 1884. Trans. Ophth. Soc. U. K., Vol. v, p. 6. 
■\ A. von Graefe's Archiv, xli, iv, p. 229. 
23 



274 DISEASES OF THE EYE. 

likely to be of most use, with warm fomentations and a pro- 
tection bandage locally during an attack. 

Deep Scleritis. — Here the whole of that part of the 
sclerotic which forms the front of the eye is more likely to be 
affected at once than in the milder form, although cases often 
enough occur where only an isolated node is present at a time. 

It is the progress of the case alone which can render the 
diagnosis between this and the milder forms certain, and hence 
the importance of a guarded prognosis in the early stages of 
every case of scleritis. In the deep form, changes — thinning 
and softening — of the scleral tissue take place, which render 
the latter less resistant, and consequently expose it to disten- 
sion by even the normal intraocular tension. The result of 
this is a bulging (staphyloma) of the anterior part of the eye- 
ball. This bulging in itself produces myopia, and has a dele- 
terious effect upon the sight ; but at a later period vision is 
often wholly destroyed by secondary glaucoma. It may 
happen that the thinning, etc., of the sclerotic affects only a 
portion, and not the whole of its anterior surface ; and in such 
a case the resulting staphyloma will be confined to that part 
of the sclerotic. A staphyloma, whether total or partial, pre- 
sents a bluish-gray appearance, due to the uveal tract shining 
through the thinned sclerotic. 

Either with or without such staphylomatous changes, scler- 
otizing opacity of the cornea may come on, and iritis, cho- 
roiditis, and opacity of the vitreous humor are not uncommon 
complications, especially in strumous subjects. Both eyes are 
usually affected. 

Causes. — Young adults are the most common subjects of 
deep scleritis, and females more often than males. Congenital 
syphilis, rheumatism, struma, and disturbances of menstruation 
are the most common assignable causes. 

Treatment. — There are few diseases less amenable to treat- 
ment. When any of the above causes can be assumed to be 



THE SCLEROTIC. 275 

present, the suitable remedies are of course indicated. Be- 
sides this, warm fomentations, dry cupping on the temple, or 
the artificial leech, complete rest of the eyes, and protection 
with dark glasses are to be recommended. 

When all acute inflammation has passed away, an iridectomy 
is sometimes indicated, either for optical purposes, when the 
pupil is obstructed by corneal opacity, or for the purpose of 
reducing glaucomatous tension, or of diminishing a staphy- 
loma. 

Injuries of the Sclerotic. — Ruptures and perforating 
wounds are those which have to be considered. Mere losses 
of substance may be said not to occur. 

The primary danger of a rupture or perforating wound of 
the sclerotic, apart from the loss of the contents of the eye- 
ball, which is often associated with it, consists in the possi- 
bility of infecting organisms being introduced into the interior 
of the eye, and there setting up serious inflammatory reaction. 

A large and gaping wound is easily recognized. A portion 
of the choroid, ciliaiy body, or iris, according to the position 
of the wound, probably lies in it, or part of the vitreous 
humor may be found in it ; while the vitreous humor, as seen 
through the pupil, will be full of blood (hemophthalmos), 
and blood may be present in the anterior chamber (hyphemia, 
b-o, iLiider ; aifxa, blood), especially if the wound be far forward. 
Small W'Ounds may be concealed by subconjunctival hemor- 
rhage, and here reduced tension of the eyeball is sometimes a 
valuable diagnostic sign. 

Clean-cut perforating wounds of the sclerotic often heal 
without inflammatory reaction, even when portions of the 
uveal tract or vitreous humor are prolapsed into it, these 
prolapsed parts becoming incarcerated in the cicatrix. Even 
irregular ruptures of the sclerotic from blow^s, with prolapse 
of uvea, and vitreous humor, and, as sometimes occurs, evac- 
uation of the lens, may heal without inflammatory reaction. 



276 DISEASES OF THE EYE. 

It may here be mentioned that these ruptures from blows 
almost always occur close to the corneal margin, and concen- 
trically with it, and lie usually near its upper, or upper and 
inner, margin. And one often sees the conjunctiva remain 
intact over the rupture, with perhaps the lens dislocated 
under it. 

When inflammatory reaction follows upon one of these in- 
juries, it may either be of the purulent or plastic form. In 
the former case all the contents of the eyeball take part in the 
suppuration, and we term it panophthalmitis, phthisis bulbi 
being its ultimate result. In the plastic form the iris and cili- 
ary body alone are implicated, and sight is slowly lost, the 
eye here, too, becoming phthisic. Of the two the latter 
process is the more serious, as it may give rise to sympathetic 
ophthalmitis — a danger which is not associated with the eye 
lost through panophthalmitis. 

Where the wound has been produced by a small foreign 
body, which has remained in the interior of the eye, the 
seriousness of the position is much aggravated. This 
matter will be discussed in chapter xiv, on Diseases of the 
Vitreous Humor. 

Treatvicni. — In cases where the wound is small no suture 
need be applied : a bandage will be sufficient to promote the 
natural tendency to healing. But where the wound is large 
and gaping, any prolapsed choroid, etc., should be first freely 
irrigated with sublimate lotion, i : 5000, and reduced as 
well as possible ; and then the margins of the wound drawn 
together by a few points of suture in the sclerotic, or, better 
still, by passing the sutures through the conjunctiva at some 
distance from the edges of the wound. The traction on the 
conjunctiva is there sufficient to close the scleral wound. A 
bandage is applied, and the patient kept quiet in bed. But 
if the injury be such — very wide wound, much loss of contents 
of the eyeball, or extensive intraocular hemorrhage — as to 



THE SCLEROTIC. 277 

render restoration of useful sight beyond reasonable hope, it 
will be wiser to remove the eyeball at once, rather than run 
the risk of sympathetic ophthalmitis without compensating 
advantage. 

Tumors of the sclerotic, as primary growths, are almost 
unknown ; but fibroma, sarcoma, and osteoma have been so 
observed. 

Pigment spots of a yellowish-brown color are often seen 
in the sclerotic close to the corneal margin. They are con- 
genital, and of no importance. Occasionally a black pig- 
mented patch may be associated with pigmented sarcoma of 
the ciliary region. 



CHAPTER X. 

DISEASES OF THE UVEAL TRACT. 

Iris, Ciliary Body, and Choroid.* 
If it be remembered that the iris, ciHary body, and choroid 
closely resemble each other histologically, that their blood 
supply is identical, and that they form with each other a con- 
tinuous membrane, it is a matter of surprise to learn that any 
one of these three divisions of the uveal tract can undergo in- 
flammation while the other two remain perfectly healthy. Yet 
this is by no means uncommonly the case. But it is, perhaps, 
more common for at least two of them, and especially the iris 
and ciliary body (iridocyclitis), to be simultaneously inflamed ; 
and the entire tract may, of course, be affected at once. Clinic- 
ally, we cannot always know whether only one or more than 
one division of the uveal tract is in a state of inflammation, and 
this uncertainty of diagnosis is particularly liable to arise when 
there is severe acute iritis ; for then the symptoms present 
might all be derived from the iritis alone. It may be taken 
for granted that in every rather severe case of iritis, particu- 
larly in those of syphilitic origin, more or less cyclitis is also 
present ; while a deep anterior chamber, tenderness on press- 
ure, or punctate deposits on the posterior surface of the cornea 
increase the suspicion. In most cases of slight iritis there is 
probably no cyclitis. 

It is only after the acute inflammatory symptoms have sub- 
sided and the pupil has become clear, that disseminated 

*;^;o/3iov, the chorion ; hence choroid, like the chorion. 
278 



THE IRIS. 279 

changes in the choroid, opacities in the vitreous humor, and 
even retinitis and optic neuritis, which may lead to optic 
atrophy, can be discovered, with their corresponding depre- 
ciation of vision. 

It is desirable, in a systematic consideration of inflammation 
of the uveal tract, to discuss it under the separate headings of 
the iris, ciliary body, and choroid ; and the same remark applies 
to the other diseases and to the injuries of this tunic. 

Iritis. 

The symptoms of iritis, more or less marked, are : 

Discoloration, loss of luster and of distinctness of pattern, 
and functional disturbances (impaired mobility) of the iris, with 
contraction of the pupil. The loss of luster and of distinctness 
of pattern is due to an alteration in the endothelium which 
covers the surface of the iris, to the presence of lymph, and to 
cloudiness of the aqueous humor. The change in color is due 
to hyperemia of the iris, as well as to the presence of the in- 
flammatory products ; a blue iris becomes greenish, a brown 
iris yellowish. The impaired mobility and the contracted 
pupil are due to engorgement of the blood-vessels of the iris, 
to spasm of the sphincter iridis, and to posterior synechise. 

Exudation of inflammatory products is present in greater or 
less degree, and may be found on either surface of the iris, in 
the pupil, in the aqueous humor, on the posterior surface of 
the cornea, and in the tissue of the iris. 

Posterior synechiae {auvlyziv, to bind togethei^ — i. e., adhesions 
between the iris and the anterior capsule of the lens — occur as 
the result of inflammatory exudation of the posterior surface 
or on the pupillary margin of the iris. The presence of 
posterior synechia is ascertained by observing the play of the 
pupil when the eye is placed alternately in strong light and in 
deep shadow, or by observing the effect of a drop of atropin 
solution on the pupil, the latter dilating only at those places 



28o DISEASES OF THE EYE. 

where there are no synechiae. If the entire pupillary margin 
have become adherent, the condition is termed complete pos- 
terior synechia, circular posterior synechia, ring synechia, or 
exclusion (or seclusion) of the pupil ; and in such cases, if of 
some standing, atropin has no effect on the pupil. If the area 
of the pupil be filled with exudation, circular synechias being 
usually also present, the condition is known as occlusion of 
the pupil. Total posterior synechia is that condition in which 
the whole posterior surface of the iris is adherent to the cap- 
sule of the lens. 

In addition to the foregoing, circumcorneal injection of the 
ciliary vessels is a common symptom in most cases of iritis. 

The subjective symptoms in iritis consist, in the first place, 
of pain, due to irritation of the ciliary nerves in the inflamed 
part. Yet this pain is not always referred to the eye itself, 
but often appears in the form of supraorbital neuralgia, 
or affecting the infraorbital division of the fifth nerve. Dim- 
ness of vision is the second subjective symptom of iritis. It 
may be due to cloudiness of the aqueous humor or cornea, or 
to exudation of lymph on the pupillary area of the anterior 
capsule of the lens, or, where the ciliary body is implicated, to 
opacities in the vitreous humor. 

Cases of iritis in which there has been no pain and no circum- 
corneal injection, and in which the failure of sight alone it is 
which brings the patient to the surgeon, are not uncommon. 
Examination then discovers the presence of extensive poste- 
rior synechiae, which have probably been gradually forming for 
a long time back. These cases of quiet iritis are, in my ex- 
perience, usually due to rheumatism {indc infra). 

A mistake into which beginners very often fall is to take a 
case of iritis to be conjunctivitis or scleritis (see pp. io6 and 
271), the " redness of the white of the eye " being that which 
misleads. The condition of the iris itself will assist chiefly in 
the diagnosis. Moreover, the pain in iritis is of neuralgic 



THE IRIS. 281 

character, but in conjunctivitis it is similar to that caused by a 
foreign body in the conjunctival sac. In iritis there is no dis- 
charge, while in conjunctivitis the eyelids are gummed in the 
morning by mucopurulent secretion. Of course iritis and con- 
junctivitis may occur together. 

Those cases of iritis in which the inflammatory exudation is 
mainly on either surface of the iris and in the pupil are the 
most common. Here the circumcorneal injection is generally 
well marked, sometimes causing elevation of the limbus of the 
conjunctiva, and even general, although slight, chemosis. In 
very mild cases, however, as also in chronic cases, the injec- 
tion may be slight. The loss of luster and of distinctness of 
pattern of the iris is well marked, and there is considerable 
change in the color of the iris. Posterior synechiae are very 
apt to form. In some rare cases of this form, an enormous 
quantity of gelatinous exudation is present in the anterior 
chamber. 

In secondary syphilis one often sees iritis of this kind. 

RJieuinatic iritis is of this form, but accompanied by circum- 
corneal injection, which is great in proportion to the other signs 
of iritis present. The pain in rheumatic iritis is often peculiarly 
severe. Yet, as I have already stated, quiet iritis is most 
often due to rheumatism. 

Gonorrheal iritis, too, is of this kind, although with it there 
is often seen the punctate deposit on the posterior surface of 
the cornea. It does not attend on, nor immediately follow, a 
gonorrhea ; but an attack of rheumatic arthritis, usually of the 
knees, always intervenes. Gonorrheal iritis is extremely rare. 

Those cases of iritis which are chiefly characterized by the 
deposit of fibrinous elements in the form of very fine yellowish 
dots on the posterior surface of the cornea, with more or less 
turbidity of the aqueous and some tendency to the formation 
of posterior synechiae, used to be, and very often are still, 
called cases of serous iritis. We know now that the inflam- 
24 



282 DISEASES OE THE EYE. 

matory product is fibrinous and not serous, and that in these 
cases the ciliary body is quite as much, if not more, affected 
than the iris, and hence that this is to be regarded as irido- 
cyclitis of a sluggish or chronic form. The fibrin passes from 
the ciliary body into the aqueous humor, and from it is precip- 
itated on the cornea in its lower quadrant by force of gravity. 
The part of the cornea thus affected is often of a triangular 
shape, the base of the triangle corresponding with the lower 
margin of the cornea, the apex being directed toward the center 
of the cornea, with the finer dots near the apex. The triangular 
shape is a mechanical result of the motions of the eyeball. 

Snellen* has ascertained the presence of very short bacilli 
in the masses of which the dots are composed. He thinks it 
probable it is these microbes (the dots contain at first only 
microbes) which produce the dots, and, by their resulting 
toxins, irritation of the uveal tract and iritis. 

In cases where the corneal deposit continues for a length of 
time, owing to resulting degeneration of the posterior epithe- 
lium, permanent secondary changes in the true cornea are 
produced, and a consequent peculiar triangular opacity at the 
lower part of the cornea will ever afterward indicate the na- 
ture of the process which has gone before. 

In this form of iritis the circumcorneal injection is slight, 
the anterior chamber is often deep, and the aqueous humor is 
sometimes cloudy. The increase in the contents of the ante- 
rior chamber frequently causes increase in the intraocular 
tension. 

Keratitis punctata is a term often given to the punctate ap- 
pearance in these cases, but it is obviously unsuitable. 

Where the inflammatory product is situated in the tissue of 
the iris the consequent swelling ma\^ be present over its whole 
extent, or may be confined to a circumscribed part of it. In 



Ophth. Rev., 1894, p. 259 



THE IRTS. 283 

the latter case the swelling is sometimes called a condyloma. 
The color of the iris changes remarkably at the affected part 
to a yellowish or reddish-yellow hue, and new vessels are 
formed in it. 

In syphilis, late in the secondary stage, a form of iritis oc- 
curs which may be always recognized as syphilitic. It is 
characterized by the formation of circumscribed tumors or 
small condylomata of a yellowish color, the rest of the iris 
being apparently intact. These tumors vary in size from that 
of a hemp-seed to that of a small pea, and are situated usu- 
ally at the pupillary margin, occasionally at the periphery of 
the iris, and very rarely in the body of the iris. There may 
be but one tumor present, and there are seldom more than 
three or four. This form is not common. Yet many authors 
hold that in most, if not all cases of syphiHtic iritis condylo- 
matous tumors are present, but of such small size as to escape 
detection with our ordinaiy clinical methods. 

Hemorrhagic iritis is not a special form of iritis, but is 
merely a severe inflammation of the iris with hyphemia. It is 
chiefly seen in iritis due to operations and injuries, in some 
cases of sympathetic iritis, and in old people. 

Syinptonis of Iritis in General. — i. Pain. This is situated 
not so much in the eye as in the brow over it, in the corre- 
sponding side of the nose, and in the malar bone, and may 
even extend to the whole side of the head. It varies in its 
intensity ; it is usually more severe at night, and is often called 
neuralgia by the patients. The form with exudation on the 
surface of the iris and in the pupil is the one attended by the 
most severe pain ; the form with punctate deposits on the 
posterior surface of the cornea as its main characteristic is 
generally unattended by pain ; while the form with marked 
circumscribed deposits or condylomata in the stroma of the 
iris is often excessively painful and again completely painless. 
2. Lacrimation and photophobia are occasionally present, but 



284 DISEASES OF THE EYE. 

never to such a degree as is often observed in certain corneal 
affections. 3. Dimness of vision. This is usually complained 
of as soon as the inflammation is pronounced. Cloudiness 
of the aqueous humor and punctate corneal deposits affect 
sight in proportion to their degree, and exudation in the 
pupil may reduce vision to a quantitative amount. 

The tension of the eye in iritis is usually normal, but in 
some violent cases it will be found to be high. 

Prognosis. — The length of duration of an attack of iritis 
cannot be foretold at the outset. Cases which are in other 
respects mild — i. e., where the pupil dilates well and rapidly 
to atropin, where the aqueous humor is clear, and where but 
little lymph is thrown out — often continue for weeks irritable 
and painful, with a marked tendency to relapse if treatment be 
at all relaxed. An attack of iritis may last from two to eight 
weeks ; the plastic form being the most rapid, and the serous 
form the slowest. Recurrences of the inflammation are com- 
mon, owing to continuance of the constitutional taint which 
gave rise to the iritis in the first instance. 

It is possible that an attack of any form of iritis, if carefully 
treated from the beginning, may leave the eye in as healthy a 
condition as before ; but it is quite as common, in spite of 
every effort, to find posterior synechiae, isolated or as a circu- 
lar synechia, left behind. The presence of a few isolated 
synechiae, if the pupil be clear, is in itself harmless to sight ; 
but if relapses take place and fresh adhesions be formed, a 
complete posterior synechia may ultimately be established. 
When this occurs, the aqueous humor being still secreted 
behind the iris, the latter becomes bulged forward, like the 
sail of a ship, until it touches the peripheral part of the cornea ; 
while the center of the anterior chamber retains its normal 
depth. This condition is very liable to induce glaucomatous 
tension (secondary glaucoma) and consequent loss of vision ; 
or, if the eye escape this danger, the traction on the ciliary 



THE IRIS. 285 

body produced by the tensely stretched iris may develop 
chronic inflammation of the ciliary body and choroid — so- 
called chronic iridocyclitis, or iridochoroiditis — and this may 
lead to diminished tension and phthisis bulbi, with detachment 
of the retina and calcification of the lens ; or, the eye having 
been first blinded by high tension, may at a later period 
undergo phthisis bulbi. 

Complete posterior synechia may of course result from the 
first and only attack of iritis, and not by means of repeated 
relapses. 

In some cases of iritis the vitreous humor becomes more or 
less opaque, and this condition does not always disappear as 
the iritis gets well ; indeed, it may not be possible to ascer- 
tain its presence until after the inflammatory process in the 
iris has subsided. Very great and permanent deterioration of 
vision may result in such instances ; and they emphasize the 
importance of a cautious prognosis at the commencement. 
There can be no doubt but that in these cases the ciliary body 
is inflamed along with the iris. 

Causes. — Iritis is not common in children, except as com- 
plicating a corneal process, or as a result of congenital syphilis 
or tuberculosis (see New Growths of the Iris, p. 292). Toward 
puberty, slight iritis is sometimes found in girls. Youth and 
middle age are the times of life in which iritis is most often 
seen, while in old age it again becomes rare. 

More than 50 per cent, of the cases depend on syphilis, 
and a large proportion of the remainder are due to rheuma- 
tism. During desquarnation after small-pox, iritis is sometimes 
observed. In metria and septicemia purulent iritis occurs, as 
also with typhoid fever,* pneumonia, and recurrent fever. 
Diabetes sometimes causes iritis. 

* Typhoid bacilli have been found in the anterior chamber in this form of iritis 
(Gillet de Grandmont, Archiv d' Ophthal., xii, x, p. 623). 



286 DISEASES OF THE EYE. 

Treatment. ^hXxo^^xn is, above every other, the most im- 
portant means. It is most commonly used in solution 
(Atrop. sulph., gr. iv ; aq. dest., 5J) as drops ; but an atom 
of sulphate of atropin in substance, placed in the conjunctival 
sac, gives a very active reaction. It is also used in the form 
of an ointment (Atrop. sulph., gr. iv ; vaselin, oj), and gelatin 
discs containing atropin are manufactured. By paralyzing the 
sphincter iridis atropin provides rest for the inflamed iris ; and 
if adhesions have already formed, the dilatation of the pupil 
may break them down, while if none are as yet present the 
dilatation will greatly aid in preventing their formation. To 
produce a maximum effect, where it is desired to break down 
adhesions, six drops of the atropin solution should be instilled 
into the eye, with an interval of from five to ten minutes be- 
tween each ; and in this way the atropin from each drop has 
time to make its way into the anterior chamber, and finally the 
accumulated effect of all six is obtained. More than one drop 
can hardly be retained in the conjunctival sac at a time. The 
usual run of cases of iritis require a drop in the eye from twice 
to four times a day, in order to maintain a dilatation of the 
pupil ad inaxiimiin, as is desirable. 

Some individuals are peculiarly susceptible to atropin 
poisoning, of which the symptoms are dryness of the throat, 
fever, fulness in the head, headache, delirium, coma. The 
antidote is morphin, of which y^ of a grain, used hypodermically, 
neutralizes -^-^ of a grain of atropin in the system. Atropin 
poisoning occurs by reason of introduction of the solution into 
the stomach through the lacrimal canaliculi and the nose and 
fauces ; and in order to prevent this the finger of the patient 
may be placed in the inner canthus, so as to occlude both 
canaliculi during, and for some moments after, the introduction 
of the drop into the eye. 

After long use of atropin the skin of the lower eyelid, or of 
both eyelids, from infiltration with the drug, often becomes 



THE IRIS. 287 

eczematous, red, swollen, and painful ; and in other cases folli- 
cular conjunctivitis is induced. If these occur, sol. extr. bella- 
donna (gr. viij ad 5J) should be substituted for atropin, and 
suitable remedies used for skin or conjunctiva. In old people 
tenesmus and retention of urine sometimes result from use of 
atropin.* 

Atropin, while it is so useful a means in the treatment of 
inflammations of the iris, ciliary body, and cornea, is of no 
benefit in many other diseases of the eye, and is positively 
harmful in some of them. It is necessary to make this state- 
ment very explicitly, for some, perhaps I should say many, 
medical men who have not devoted attention to the subject of 
eye-disease habitually include atropin in every eye-lotion they 
prescribe. If the disease prescribed for be conjunctivitis, as it 
very often is, the atropin is calculated rather to increase than 
to relieve the conjunctival affection ; while if the patient be 
advanced in life, there is always the danger that a tendency to 
glaucoma ma}^ be present, and in such a case the dilatation of 
the pupil caused by the atropin will be sufficient to bring on an 
attack of acute glaucoma. In these da}'s it falls to the lot of 
mos't ophthalmic surgeons to be called, at one time or another, 
to a case of acute glaucoma brought on by the gratuitous use 
of atropin in this manner. It is to be feared that the reason 
for this random prescribing of atropin is to be found in an 
ignorance of diagnosis, which leads practitioners to throw 
atropin wdth a number of other drugs into their eye-lotions in 

"^ Scopolaniin, a drug which has the same effects on the eye as atropin, has re- 
cently been used by Raehlraann and others. It is much stronger than atropin, a 
solution of I : 500 being equal to a one per cent, solution of the latter. It also 
acts more rapidly, and its effect passes off more quickly. When the pupil dilates 
under its influence, it sometimes assumes an oval or egg-shaped form, due to the 
action beginning below. (See Klin. Monatsbl. f. Augenheilk., February, 1893, 
and Bdljarminozv Centralblatt f. prakt. Augenheilk., August, 1893, p. 187.) 
Some use of the drug at the National Eye and Ear Infirmary has verified 
the reports given of its action. 



288 DISEASES OF THE EYE. 

the hope that some of the ammunition will hit the mark, 
wherever the latter may be. 

Dark protection-spectacles should be worn by patients suf- 
fering from iritis ; and in severe cases they should be confined 
to a dark room, and even to bed. 

In that form of iritis where the inflammatory exudation is 
mainly on the surface of the iris and in the pupil, iodid of 
potassium or perchlorid of mercury may be given internally. 
If there be much irritation, pericorneal injection, or chemosis, 
leeching at the external canthus is of use. Intermittent warm 
fomentations, every two hours, promote healthy vascular re- 
action. Pain is to be relieved by hypodermic injections of 
morphin, and by chloral internally. 

In rheumatic iritis and in iritis due to diabetes, salicylate of 
sodium in large doses (20 to 30 grs. every three hours), has 
often a remarkably favorable effect. 

In those cases in which punctate deposits on the cornea are 
the chief characteristic — so-called serous iritis — a small quantity 
of atropin will suffice, as there is little tendency to the forma- 
tion of synechiae, and the irritation being slight, leeching is 
unnecessary. The skin (pilocarpin hypodermically, Turkish 
baths, and dry rubbing), kidneys, and bowels should be acted 
on ; and to the diuretics* prescribed some iodid of potassium 
may be added. Turpentine in 5j doses, as recommended by 
Carmichael, of Dublin, is often a useful remedy here. Mr. 
John Tweedy prefers Chian turpentine in five-grain doses every 
three, four, or six hours. 

Blistering on the temples or behind the ears is with many 
surgeons a favorite remedy. It adds to the annoyance of the 
patient, but I have no belief in it as a remedy in this, or indeed 
in any other eye disease. 

Great care is required in watching the tension of the eye in 
this form of iritis, and if it be found to increase and to remain 
high for three or four days, paracentesis of the anterior cham- 



THE IRIS. 289 

ber must be performed to reduce it temporarily while the iritis 
is still progressing toward cure. This little operation will also 
be called for if there be much deposit on the posterior surface 
of the cornea, as by means of it the deposit, to a great extent, 
may be floated away. (For mode of performing paracentesis 
see p. 170.) 

Where the exudation is in the form of circumscribed tumors 
or condylomata in the stroma of the iris, it is important to ob- 
tain rapid absorption of the inflammator}' products, which are 
so abundantly thrown out, and which, in an organ like the eye, 
would soon cause extensive destruction. Consequently, the 
system should be put under the influence of mercury as quickly 
as possible, by the use of inunctions of mercurial ointment or 
by small doses of calomel internally ; and this treatment is in- 
dicated even when the inflammation is not of syphilitic origin. 
Warm fomentations are useful. An after-treatment with iodid 
of potassium is to be employed. 

In syphilitic iritis, von Graefe w^as fond of the following 
formula : 

R. Hydrarg. biniodid., gr. vj 

Potass, iodidi, ^iss 

Aq. destill. , | ss 

Syr. aurant., ... ^ iiss. M. 

A teaspoonful to be taken once a day. The dose to be gradually in- 
creased. 

In purulent iritis quinin and salicylate of sodium are the most 
suitable internal remedies. 

Injuries of the Iris. 
Punctured wounds of the eye frequently implicate the iris, 
but rarely do so without also injuring the ciystalline lens or 
ciliary body, on which then the 'chief interest centers, as being 
the organs from which serious reaction is apt to emanate. If a 
simple incised wound of the iris be observed, it may be re- 
garded as of little importance, for inflammator)^ reaction need 



290 DISEASES OF THE EYE. 

not be feared, and any extravasation of blood into the anterior 
chamber (hyphemia) becomes absorbed, while, as a whole, the 
functions of the iris will probably not be affected. 

Foreign bodies of small size, such as bits of steel or iron, 
may perforate the cornea and fasten in the iris, the puncture 
in the cornea closing rapidh% and possibly no aqueous humor 
being lost. It is necessary always to remove such a foreign 
body without delay, although for some time it may cause no 
reaction. An incision should be made with a Graefe's knife 
at the margin of the cornea corresponding to the position o^ 
the foreign body, and the portion of iris containing the foreign 
body is then removed with forceps and scissors. 

Blows on the eye are apt to cause one of several remark- 
able lesions of the iris, namely : 

I. Ii'idodialysis (^lpt<;, didkoatq, a separating) — /. c, separation 
of the iris from its attachment to the ciliary body, which is 

usually accompanied by consider- 
able hyphemia. As much as one- 
half of the circumference of the 
iris may be involved in the lesion 
(Fig. 87), or the latter may be so 
small as to be detected only by 
aid of light transmitted to the eye 
by the ophthalmoscope ; and then 
not only the physiologic pupil, but also the minute marginal 
traumatic pupil will be illuminated. The functions of the eye 
after such injury, even when extensive, may be but little dis- 
turbed, or there may be monocular diplopia. 

Restoration to the normal state in these cases rarely takes 
place. I have observed one case in which the iridodialysis — 
a very minute one — was healed, and there is one other such 
case recorded. The lengthened use of atropin is the most 
likely way to promote such a result, which can only be hoped 
for if the iridodialysis be not extensive, and the case be seen 
early. 



r^#fltt 




THE IRIS. 291 

2. Retroflexion of the Iris. — A portion of the iris in its 
entire width becomes folded back on the cihary processes, 
giving the appearance of a coloboma produced by a wide and 
peripheral iridectomy. In a true coloboma the ciliary pro- 
cesses would be easily seen, but not so in retroflexion, for the 
processes, being covered by the retroflexed iris, present a 
smooth surface. A slight dislocation of the lens in the direc- 
tion away from the iris lesion is often observed. Retroflexion 
of the iris cannot be cured. 

3. RiipUire of the Sphincter Iridis. — There are not many 
cases of this lesion recorded ; although, according to Hirsch- 
berg,* in all cases of permanent traumatic mydriasis the mar- 
gin of the pupil is torn. My observations do not agree with 
this view of Hirschberg's, nor do I agree with him in think- 
ing, as he seems to do, that rupture of the sphincter would 
be sufficient to account for traumatic mydriasis. This condi- 
tion is also incurable. 

4. Traumatic Aniridia. — The whole iris may be torn from 
its ciliary insertion and found lying in the anterior chamber or 
under the conjunctiva, having in the latter case passed through 
a rent at the corneo-scleral margin. 

5. Anteversion. — This must always be accompanied by 
iridodialysis. The detached portion of iris is then twisted on 
itself, so that the uveal surface is turned to the front. f 

6. Traumatic Mydriasis. — Permanent dilatation of the pupil 
after a blow is not very uncommon, and is usually referred to 
paralysis of the sphincter, the result of concussion of the 
dehcate nerve-endings in the sphincter itself (See above, 
under Rupture of the Sphincter Iridis.) 

* CentraJbl.f. Angenheilk., 1886, p. 368. 
t L. Werner, in Ophih. Rev., 1887, p. 104. 



292 DISEASES OF THE EYE. 

New Growths of the Iris. 

Cysts. — These vary from a very small size to that which 
would fill the anterior chamber. They may have either serous 
or solid contents. The serous kind was said to result always 
from a trauma causing an anterior synechia, or otherwise 
shutting off a fold of the iris, which became distended into a 
cyst by accumulation of aqueous humor. A case, however, 
which was not preceded by a trauma has come under my 
notice. The cysts with solid contents (epidermoid elements) 
are believed to have their origin in an eyelash or morsel of 
epidermis, which may have made its way into the anterior 
chamber by occasion of a perforating corneal wound. All these 
cysts are sources of serious danger to the eye (iridochoroiditis, 
glaucoma, etc.), and it is stated may even be the cause of 
sympathetic ophthalmitis, and hence their removal is called 
for. This can be effected without much difficulty if the tumor 
be small, but if it have attained a large size the attempt 
may be unsuccessful. A long incision should be made in the 
corneo-scleral margin, and the cyst, along with the portion of 
iris to which it is attached, drawn out and cut off. 

Granuloma is the name given to a benign neoplasm of 
the iris, of which the structure resembles granulation tissue. 
Clinically it is a small pale tumor, or there may be several 
such tumors, which gradually grow to fill the anterior cham- 
ber, rupture the cornea, and finally induce phthisis bulbi. It 
is held by some that these growths depend on a syphilitic 
taint, and by others that they are tubercular. 

Tubercle (Tubercular Iritis). — This disease occurs gen- 
erally in children or young adults, who may or may not 
present evidence of general tuberculosis, such as enlarged or 
caseating glands, or diseases of joints, etc. It is met with 
in two forms, viz. : disseminated or miliary tubercle, and 
conglomerate or solitary tubercle. 



THE IRIS. 293 

Miliary tiiberadosis of the iris is a relatively mild form, 
which presents the dinical appearances of a chronic iritis, 
sometimes with keratitis punctata ; but it is chiefly charac- 
terized by the formation of a number of grayish or cinnamon- 
colored, semi-translucent nodules on the surface of the iris 
and at the angle of the anterior chamber. Occasionally they 
are not very numerous. The disease may either run its course, 
and finally cause shrinking of the eye from plastic irido- 
cyclitis, or it may subside even spontaneously. It is to this 
form of iritis that Leber * has given the name attenuated 
tuberculosis of the iris ; but it is not due to any attenuation 
of the virus, for inoculation in the anterior chamber of a 
rabbit's eye of an excised portion of such an iris produces 
severe local and general tuberculosis. This form of tuber- 
culosis of the iris is probably the result of some constitutional 
peculiarity, t 

Solitary tubercle may be accompanied by a few smaller 
growths, but it generally begins as a single yellowish-white 
tumor, often without iritis, which gradually increases in size 
until it may fill the anterior chamber. It finally involves the 
cornea, which it perforates, forming a fungating mass, and 
this subsequently breaks down, leaving only a small stump in 
the socket. Microscopically, both varieties present the usual 
structure of tubercle, but bacilli *are very difficult to detect in 
either of them. 

Treatment in the miliary forms consists of the usual local 
and constitutional means. Internal administration of creosote 
has recently been recommended. If the disease continue to 
progress enucleation may be necessary. 

Should a solitary tubercle be seen in an early stage it may 
be removed by an iridectomy ; but if the disease has advanced 

* Bericht der Ophth. Gesellschaft zu Heidelberg, 1 89 1, p. 44. 
t Samelsohn, ibid., 1893, p. 75. 



294 DISEASES OF THE EYE. 

too far, or the iridectomy has failed, the eye must be extir- 
pated. Operative treatment will depend very much on the 
view which the surgeon takes of the origin of the disease. It 
has until recently been generally believed that, while tubercle 
of the choroid was a disease secondary to tuberculosis else- 
where, tubercle of the iris was a primary affection, and as such 
necessitated immediate enucleation of the eye in order to 
prevent it from becoming a source of general infection. The 
impression, however, seems to be growing that tubercle of the 
iris is also a secondary affection, and that consequently enucle- 
ation is not always indicated. Of course in those cases, which 
are not uncommon, where both eyes are affected, enucleation 
cannot be entertained. 

Primary sarcoma (or melanosarcoma) is a rare disease of 
the iris. When the tumor is very small it may be removed 
by an iridectomy, and in this way an attempt made to preserve 
the eye ; but when it has attained any size the whole eyeball 
must be removed. 

Ophthalmia nodosa is a very rare affection, of which 
about seven cases have been recorded.* It is caused by the 
irritatinsr secretion contained in the hollow hairs of certain 

o 

caterpillars. In nearly all cases there w^as a history of cater- 
pillars having accidentally come into forcible contact with the 
eye. The disease, which is 'very chronic, is characterized by 
the presence of small, hard nodules in the conjunctiva and 
iris, and may lead to severe iridocyclitis. The diagnosis is 
confirmed by the presence of brownish hairs, or by the ex- 
amination of an excised nodule, which shows the hair in sec- 
tions as a yellow oval body with a central cavity. 



*Kruger, A fr/tivf. Ophthalm. (German ed.), Vol. xxiv, p. 147. This paper 
contains abstracts of previously observed cases. 



THE IRIS. 295 

Congenital Malformations of the Iris. 

Heterophthalmos (irspoq, different ; d^pOaliJ.oi). — This term 
indicates that the color of the iris in one eye is different from 
that in the other. 

Corectopia (y-opf], the pupil ; h.xo-oq^ out of position), or 
malposition of the pupil. The pupil sometimes "occupies a 
position further from the center of the iris than normally. 

Polycoria {jzoXoq, many ; y.op-q, the pupil). — Where there is 
more than one pupil. The supernumerary pupil may be sepa- 
rated by only a small bridge from the normal pupil, or it 
may be situated very near the periphery of the iris. In neither 
case has it a special sphincter. 

Persistent pupillary membrane appears in the form of 
very fine threads stretched across the pupil. They cannot be 
mistaken for posterior synechiae, as they are attached to the 
anterior surface of the iris some distance from the margin of 
the pupil. They do not interfere with the motions of the 
pupil, nor with vision. 

Coloboma (xo;.o/9oc, maimed). — This is a cleft in the iris 
caused by an arrest of development which results in incom- 
plete closure of the choroid fissure. It is situated almost 
always in the lower inner quadrant, at a position correspond- 
ing to the choroid fissure in the fetus, and it varies much 
in size in different cases. It is sometimes continued into the 
ciliary body and choroid, and may be present in both eyes, 
and a notch at a corresponding situation in the crystalline lens 
is not uncommon. The sphincter lines the edges of the colo- 
boma, thus distinguishing it from the defect which results 
from iridectomy. When uncomplicated it causes little or no 
defect of vision. 

Irideremia {'tpiq, ^p-qiua, want of). — This may be complete 
or partial. In the latter case it may be the inner circle which 
is wanting, giving the pupil the appearance of dilatation with 



296 DISEASES OF THE EYE. 

atropin. Where the entire iris is absent, the ciHary processes 
can be seen all around. The condition may be double-sided. 
The patients suffer chiefly from dazzling by light, for which 
either protection or stenopeic spectacles are to be prescribed. 

Operations on the Iris. 

Iridectomy. — This is performed for optic purposes, as in 
zonular cataract, corneal opacities, or closed pupil ; for anti- 
phlogistic purposes, as in recurrent iritis, etc. ; to reduce ab- 
normally high intraocular tension in primary and secondary 
glaucoma ; and for the removal of tumors or foreign bodies 
in the iris. 

The instruments required are a spring speculum ; a fixation 
forceps, with spring catch (Fig. 92) ; a lance-shaped iridectomy 
knife (keratome) (Fig. 88) or a Graefe's cataract knife ; a bent 
iris forceps (Fig. 89) or a Tyrrell's hook (Fig. 90) ; iris scissors 
curved on the flat (Fig. 91), or de Wecker's scissors; and a 
small spatula. 

TJie ividtli of the colobonia depends a good deal on the length 
of the corneal incision, for it cannot be wider than the incision 
is long. Its depth depends on the proximity of this incision 
to the corneo-scleral margin. If a wide and very peripheral 
coloboma be desired, the incision must be long, and must lie 
actually in the corneo-scleral margin ; the iris forceps being 
then introduced, a portion of the iris corresponding to the 
length of the incision may be seized and cut off, and a coloboma, 
as at figure 93, produced. Somewhat inside the corneal mar- 
gin will give a pupil, as in figure 94. A narrow coloboma (Fig. 
95) is obtained by a short corneal incision, which may be more 
or less peripheral as circumstances require, and by using a 
Tyrrell's hook, instead of an iris forceps, for catching and 
drawing out the iris. 

In glaucoma, a wide and very peripheral coloboma is re- 
quired. For antiphlogistic purposes a wide iridectomy is 



THE IRIS. 297 

also necessary ; but for optic purposes a narrow iridectomy is 



Fig. 88. 



Fig. 



Fig. 90. 




required, because with a wide coloboma the diffusion of light 
may be very troublesome to the patient. 
25 



29$ 



DISEASES OF THE EYE. 



The best position for an iridectomy for glaucoma, or for 
antiphlogistic purposes, is in the upper quadrant of the iris, 
as there the subsequent dazzling by light and the disfigure- 
ment are least. But the position, by preference, for an optic 
pupil is below and to the inside, being that most nearly in 
the direction of the axis of vision. If, however, this position 
be occupied by a corneal opacity, the coloboma should be 




Fig. 92. 

made directly downward ; or if that place be ineligible, then 
downward and outward, or directly downward, or directly 
inward. The upward positions are not satisfactory for optic 
pupils, owing to the overhanging of the upper lid ; but yet 
it often happens that we have no other choice. 

/;/ tJie performance of an iridectomy the eye should be fixed 
with a forceps at a position on the same meridian as that 






Fig. 93. 



Fig. 94. 



Fig. 95. 



in which the coloboma is to lie, but at the opposite side of 
the cornea, and close to the latter. The point of the lance- 
shaped knife is then to be entered almost perpendicularly to 
the surface of the cornea, and made to penetrate the latter. 
The handle of the knife is then at once lowered, and the 
blade passed on into the anterior chamber in a plane parallel 
to the surface of the iris, until the incision has attained the 



THE IRIS. 299 

required length. The handle of the knife is now lowered still 
more, so as to bring the point of the blade almost in contact 
with the posterior surface of the cornea, in order to prevent any 
injuiy to the lens in the next motion. The knife is then very 
slowly withdrawn from the anterior chamber. At the same 
time the aqueous humor flows off, and the cr}-stalline lens 
and iris come forward. The fixation forceps is now given 
over to the assistant, and the bent iris-forceps, held in the 
left hand, is passed closed into the anterior chamber, its 
points directed toward the posterior surface of the cornea, so 
as to avoid entangling it in the iris. When the pupillary 
margin has been reached, the forceps is opened as widely 
as the corneal incision will permit, and the corresponding 
portion of the iris is seized and drawn out to its full extent 
through the corneal incision. With the scissors held in the 
other hand, the exposed bit of iris is snipped off quite close 
to the corneal incision. Care should now be taken that the 
angles of the coloboma do not remain in the wound ; and if 
they are seen to do so they must be reposed by stroking 
the region of the incision with a hard-rubber spoon, or by 
actually pushing them into their places genth- with the spatula. 
Iridotomy. — For description and uses of this operation 
see chapter xiii. 

Cyclitis (Inflammation of the Ciliary Body). 

Cyclitis is often present with inflammatory affections of the 
iris or choroid, although its presence in many of these cases 
cannot be clinically determined. 

TJie symptoms of cyclitis, although not always all present, are 
marked circumcorneal injection, ciliary neuralgia, pain on pres- 
sure of the ciliary region, very deep anterior chamber, opacity 
in the anterior part of the vitreous humor, punctate deposits on 
the posterior surface of the cornea, and sometimes hypopyon 
in the anterior chamber. Edema of the margin of the upper 



300 DISEASES OF THE EYE. 

lid frequently occurs, for instance, in cyclitis after cataract ex- 
traction. 

There are three forms of cyclitis : 

In some severe cases where there is much plastic exudation, 
the circumcorneal injection is very decided, and there is venous 
congestion of the iris. The anterior chamber is deep, owing 
to retraction of the periphery of the iris by inflammatory exuda- 
tion in the ciliary body, and for the same reason the pupil is 
dilated. The inflammation may extend to the iris or to the 
choroid, in which latter case the vitreous may become very 
opaque. Violent ciliary pains attend the affection, and the eye- 
ball is very tender on pressure of the ciliary region. The 
intraocular tension is reduced. 

Again, in other cases the circumcorneal injection is but 
slight. The anterior chamber is often at first deeper than 
normal, owing to hypersecretion of aqueous humor from the 
ciliary body ; there are punctate opacities on the posterior 
surface of the cornea, so-called keratitis punctata ; and the 
anterior part of the vitreous humor is filled with a fine dust- 
like opacity. Iritis may come on, and the danger of glauco- 
matous increase of tension is very great. Unless increase of 
tension gives rise to it, pain does not often attend this form. 

In purulent cyclitis the circumcorneal injection is very well 
marked. The vitreous humor is filled with membranous 
opacities. There is hypopyon in the anterior chamber, which 
has the characteristic of appearing and disappearing at in- 
tervals of a few days. There is severe ciliary neuralgia, and 
purulent iritis or choroiditis, or both, are apt to supervene. 

Prognosis. — In an early stage all these forms are capable of 
undergoing cure and of leaving the eye in a fairly useful con- 
dition. On the other hand, cyclitis with punctate corneal 
opacities, as already stated, is liable to produce secondary 
glaucoma ; while the purulent form leads to atrophy of the 
iris and choroid, disorganization of the vitreous humor, de- 



THE CILIARY BODY. 301 

tachment of the retina, cataract, and phthisis bulbi ; and the 
form with much plastic exudation, in addition to serious 
damage to the affected eye, similar to that produced by puru- 
lent cyclitis, has, more than either of the other forms, the 
tendency to cause sympathetic uveitis of the other eye. The 
shrunken eyes resulting from the affection are often veiy liable 
to attacks of inflammation, and frequently remain painful to 
the touch, circumstances which indicate that chronic cyclitis is 
still present, and consequently such stumps are a constant 
source of danger to the sound eye. 

Causes. — Primary idiopathic cyclitis, except the form with 
punctate corneal opacities, is a rare affection. Traumata are 
the most common causes of the affection. Both the plastic and 
the purulent forms are liable to occur after cataract operations. 

T/ie treatment for cyclitis is similar to that for iritis. Leech- 
ing at the outer canthus is often of great benefit. 

Injuries of the Ciliary Body. 
Punctured wounds, and foreign bodies perforating the 
sclerotic at a distance of about five mm. around the cornea, 
are almost certain to implicate the ciliary body. If there be 
no prolapse of the ciliary body, nor any foreign body in the 
interior of the eye, the sclerotic wound may heal by aid of a 
bandage without further ill results. If a prolapse of the 
ciliary body or iris be present, it is to be abscised ; and if the 
sclerotic wound be large, it may be thought desirable to unite 
its margins with sutures. Wounds of the ciliary body are apt 
to cause cyclitis, especially if the former be caught in the 
sclerotic wound in healing, or if a foreign body be present in 
it, or indeed anywhere within the eye ; and this traumatic 
cyclitis is more likely to produce sympathetic ophthalmitis 
than the idiopathic form. Hence a region around the cornea 
about five mm. wide is aptly termed by Nettleship the '' dan- 
gerous zone." 



302 DISEASES OF THE EYE. 

New Growths of the Ciliary Body. 

Sarcoma of the ciliary body is generally pigmented, and 
often passes unobserved, until it attains considerable size as 
a brown mass, which was at first concealed from view by the 
iris. Occasionally it makes its first appearance at the angle 
of the anterior chamber. It runs the same course as sarcoma 
of the choroid. Removal of the eyeball is indicated, and 
will often for a time be declined by the patient, as sight may 
be but slightly affected in the early stages. 

Myosarcoma originating in the ciliary muscle has been 
observed a few times. 

Carcinoma. — Primary carcinoma of the ciliary body is an 
extremely rare disease. Two cases have been recorded recently 
by Lagrange * and Collins. f Its occurrence in this situation 
is easily explained if the ciliary body, which secretes the in- 
traocular fluid, has a glandular structure, and from the re- 
searches of Collins and Nicati J there seems to be every reason 
to believe that it does contain tubular glands. 

Secondary carcinoma may occur in the ciliary body as in 
the choroid (p. 311), but is very rare. 

Choroiditis. 

There are two great forms of inflammation of the choroid : 
the exudative and the purulent. Of the exudative form, again, 
there are several kinds, namely : disseminated choroiditis, central 
choroiditis, central senile choroiditis, guttate choroiditis, and 
syphilitic choroidoretinitis. 

Disseminated Choroiditis. — The usual ophthalmoscopic 
appearances of this disease consist either in round white spots 

">^ "Etudes sur les tumeurs de I'oeil," etc., Paris, 1893, p. 93. 
t Traits. Ophthal. Soc. Un. K.,\o\. xi, p. 55. 
\ Archives d'' Ophthalmologie, 1 890, p. 490. 



THE CHOROID. 303 

of different sizes with irregular black margins, or in small 
spots of pigment, these changes being surrounded by healthy 
choroid tissue ; or there may be few or no white patches, but 
rather spots of pigment surrounded by a pale margin. The 
retinal vessels pass over, not under, the patches. The number 
of these patches or spots varies according to the intensity of 
the disease. Their position is at first at the periphery of the 
fundus only, but later on they appear also about the posterior 
pole of the eye. 

These appearances represent a rather late stage of the 
disease, the early stage not usually coming under observation. 
It consists in small circumscribed plastic exudations into the 
tissue of the choroid, which, seen with the ophthalmoscope, 
give the appearance of pale pinkish-yellow spots. The 
exudations may undergo absorption, leaving the choroid in a 
fairly healthy state ; but more usually they give rise to 
atrophic cicatrices, in which the retina becomes adherent, with 
proliferation of the pigment-epithehum la}-erin their neighbor- 
hood, and hence the white patches with black margins above 
described. 

Sometimes, in addition to the above changes, the pigment- 
epithelium layer all over the fundus becomes atrophied, expos- 
ing to view the vascular network of the choroid, while here 
and there small islands of pigment are present. 

Opacities in the vitreous humor are sometimes found. 

Symptoms. — Diminution in the visual acuity, especialh* if 
the macula be involved ; there may also be subjective sen- 
sations of light or colors, positive scotoma (a dark area visible 
to the patient), and distortion of objects (metamorphopsia), or 
alteration in their size (megalopsia and micropsia). Night- 
blindness is not uncommon. 

Causes. — Disseminated choroiditis is due to acquired syphilis 
in a considerable number of the cases. But in a very large 
proportion of cases no ascertainable cause ^ exists ; and these, 



304 DISEASES OF THE EYE. 

there is reason to suspect, are congenital, and probably many 
of them are dependent on an inherited syphilitic taint. In 
eyes with congenital cataract patches of choroiditis are often 
found. 

Prognosis. — Disseminated choroiditis is always a serious 
disease, and complete recovery cannot be looked for. The 
degree of defect of sight it causes depends much on the extent 
to which the region of the macula lutea has become involved. 

Treatment. — In fresh cases due to acquired syphilis a pro- 
longed but mild course of mercurial inunctions is the most 
suitable measure, to be followed by a lengthened course of 
treatment with iodid of potassium. Where an inherited 
syphilitic taint is suspected, iodid of iron or iodid of potassium 
internally may be of use ; while in the cases due to other 
causes small doses of perchlorid of mercury may be given ; 
and in all cases, from whatever cause, dry cupping on the 
temple, or even the artificial leech, should be employed. Dark 
protection-spectacles should be worn, and absolute rest of the 
eyes from all near work insisted upon so long as the disease is 
active. Subconjunctival injections of corrosive sublimate are 
also used in these cases (see p. 177). 

Syphilitic Choroidoretinitis. — See Syphilitic Retinitis, 
chapter xv. 

Central Senile Guttate Choroiditis. — Under this name an 
appearance has been described by Mr. Waren Tay and others 
which consists of fine white, pale yellow, or glistening dots, 
best seen in the upright image, and situated chiefly about the 
macula lutea, or between this and the optic papilla. These 
dots are due to colloid degeneration, with chalky formations in 
the vitreous layer of the choroid * which give rise to secondary 
retinal changes. The functions of the retina usually suffer in 
a marked manner, so that a partial central scotoma may be 

* Hirschberg and others, Ce)ttralbl. f. prakt. Aiigenheilkunde, 1884, p. 46. 



THE CHOROID. 305 

produced ; but some cases have been observed in which vision 
was but little, or not at all, affected. 

This disease attacks both eyes, either simultaneously or with 
an interval, and is most often seen in persons of advanced life, 
although also found in middle age, and even in youth. It 
should always be looked for in cases of incipient cataract ; for 
when the lental opacity is more advanced it cannot be seen, 
while functional examination does not then detect it. 

Treatment is of no avail. 

Central choroiditis is an exudation at the macula lutea, 
without any similar disease elsewhere in the fundus. Absolute 
central scotoma is its prominent symptom, and syphilis its 
usual cause. 

Treatment. — Active mercurialization ; and where this can be 
adopted early, the prognosis for recovery of sight is fair. 

Central Senile Areolar Atrophy of the Choroid. — Al- 
though this is not an inflammatory process, yet it is most con- 
venient to refer to it here. It is not a very rare disease, and 
presents the appearance of a white patch, often of considerable 
extent, at and around the macular region. I think I have 
observed that in some cases a hemorrhage in the choroid and 
posterior layers of the retina formed the starting-point of the 
disease. The retinal functions always suffer much ; for an 
absolute central scotoma is produced, which renders all near 
work impossible, although locomotion is not much impeded, as 
the periphery of the field remains intact. The discovery of the 
presence of this disease, after a cataract has been successfully re- 
moved, is sometimes a source of intense disappointment, both 
to patient and surgeon, which cannot be guarded against un- 
less it has been noted while the cataract was still incipient. 

Treatment is of no avail. 

Purulent Choroiditis. — This consists at first in a purulent 
extravasation between the choroid and retina, and into the 
vitreous humor, recognizable by the yellowish reflection ob- 
26 



3o6 DISEASES OF THE EYE. 

tained from the interior of the eye on illuminating it. The eye- 
ball may become hard, the pupil dilated, and the anterior 
chamber shallow. Purulent iritis, with hypopyon, soon comes 
on, and the cornea may also become infiltrated and slough 
away. There is usually considerable chemosis. The eyeball 
is pushed forward by inflammatory infiltration of the orbital 
connective tissue. The eyelids are swollen and congested. 
There is intense pulsating pain in the eye, and radiating pains 
through the head ; and in this stage all the tissues of the eyeball 
are engaged in the purulent inflammation, and the condition 
is termed panophthalmitis. 

Purulent choroiditis does not always reach this latter stage, 
but may remain confined chiefly to the choroid, vitreous 
humor, and iris. The pain in such cases is not severe ; and 
when the affection occurs in children it may be mistaken for 
glioma ; indeed, the name pseudoglioma has, unfortunately, 
been given to it. It is distinguished from the malignant 
disease by the muddy vitreous usually present with it, by the 
posterior synechiae, and by the retraction of the periphery of 
the iris, with bulging forward of its pupillary part. 

Prognosis. — The ultimate result in the vast majority of 
cases is loss of sight, with phthisis bulbi. The severe cases 
go on to bursting of the eyeball through the cornea or sclerotic, 
after which the pain subsides. It would seem from the de- 
scription of authors who have seen much of epidemic cerebro- 
spinal meningitis (Niemeyer), that a certain number of cases 
of iridochoroiditis occurring in the course of that disease do 
recover with retention of good sight. 

The shrunken eyeballs produced by panophthalmitis are not 
generally painful on pressure, nor are they very liable to give 
rise to sympathetic ophthalmitis, which latter observation is 
also true of the acute purulent process itself. 

Causes. — The most common causes of purulent choroiditis 
are wounds of the eyeball, whether accidental or operative ; 



THE CHOROID. 307 

foreign bodies piercing and lodging in the eyeball ; and 
purulent keratitis. It may also come on suddenly in eyes 
which are the subjects of incarceration of the iris in a corneal 
cicatrix. 

It is seen as embolic or metastatic choroiditis, in connection 
both with epidemic and sporadic cerebrospinal meningitis 
(Chap, xvii) ; in some cases of metria, similarly as purulent 
retinitis (Chap, xv) ; in pyemia of the ordinary type ; and in 
endocarditis. 

In infancy and childhood, besides its occurrence with 
cerebrospinal meningitis, it has been known to be caused by, 
or associated with, inherited syphihs, measles, bronchitis, 
diarrhea, w^hooping-cough, and omphalophlebitis ; and it is 
more than probable that in every instance some infective 
blood-disease is the fundamental cause of the process, although 
it may not always be possible to detect the existence of that 
blood-disease. 

Treatment may be said to be powerless in this disease. 
The most one can do is to try to diminish the pain by warm 
fomentations, poultices containing powdered conium leaves, 
hypodermic injections of morphin, or, finally, by giving exit 
to the pus by a free incision in the eyeball, followed by a 
copious irrigation with weak sublimate lotion, so as to wash 
out the whole contents of the scleral cavity. Quinin and 
chlorate of potash are suitable internal remedies. 

I agree with those who think that enucleation of the eyeball 
should not be undertaken during purulent choroiditis in the 
acute stage, as it is liable to lead to purulent meningitis and 
death ; but there are surgeons who do not recognize any such 
danger, and who practise enucleation in this condition. 

Posterior Sclerochoroiditis, or Posterior Staphyloma. 
— This condition is described in connection with myopia 
(p. 51), which is its almost constant cause. 

Detachment of the Choroid. — As the result of copious 



3o8 DISEASES OF THE EYE. 

loss of vitreous, during operations or from injury, detachment 
of the choroid is not uncommon, but it does not require to be 
specially diagnosed in these instances, and therefore it is not 
important to consider it further here. 

But idiopathic detachment of the choroid, although ex- 
tremely rare, is of importance as forming a well-defined diseased 
condition in itself. 

TJie opJithabnoscopic appearances here are apt to be taken 
at first glance for a simple detachment of the retina, or for 
leukosarcoma ; but on closer inspection the choroid stroma 
is observed to lie immediately behind the detached retina, and 
its vessels, etc., are seen in the upright image by aid of the 
same lens as are the retinal vessels. The choroid is not com- 
pletely detached, but is separated from the sclerotic in several 
different places, and these detachments are seen in the form 
of apparently solid hemispheric protuberances rising abruptly 
from the fundus into the vitreous humor. In other places the 
choroid is in contact with the sclerotic, although in some of 
these positions there may be detachment of the retina alone. 
The vitreous humor is more or less opaque. Needless to say, 
vision is greatly lowered or quite destroyed. 

It is probable that a chronic choroidoretinitis has been an 
antecedent condition in all of these cases. Indeed, there 
often are signs of old retinitis present, such as perivasculitis 
and connective-tissue striation, and in one case a retinitis was 
actually observed long before the detachment of the choroid 
came on. Adhesions between the choroid and sclerotic are 
formed in consequence of this inflammation, and then inflam- 
matory exudation takes place behind the choroid, and sepa- 
rates it from the sclerotic, where it happens not to be adherent 
to the latter. 

The process ends either in phthisis bulbi, in consequence of 
vascular changes and disturbances of nutrition, or in cure of 
a certain kind, in so far as by absorption of some of the exu- 



THE CHOROID. 309 

dation, and by alteration of the remainder of it into connec- 
tive tissue, a return of the choroid and retina to their normal 
position is rendered possible ; but even then restoration of 
sisfht, with tunics so disorg-anized, cannot be looked for. 

Treatment hitherto seems to have been of no avail. Prob- 
ably active mercurialization might afford the best chance of 
doing good should a case come under notice. 

In'juries of the Choroid. 

Small foreign bodies may pierce the sclerotic, or the 
cornea and lens, and lodge in the choroid, and can often there 
be detected with the ophthalmoscope. They require operative 
removal by the magnet, if metallic ; or if this cannot be carried 
out, or that the foreign body is non-metallic, the eyeball must 
be removed, to avert sympathetic ophthalmitis. 

Incised wounds of the sclerotic very frequently involve 
the choroid (see p. 275). 

Rupture of the choroid is often produced by blows on the 
eye, and is seen with the ophthalmoscope as a whitish-yellow 
(the color of the sclerotic) crescent some two or three papilla- 
diameters in length, and one or so distant from the optic en- 
trance, the concavity of the crescent being directed toward 
the papilla. Immediately after the accident, extravasated 
blood sometimes prevents a view of the rupture. Some 
choroiditis may result, but when this passes away good vision 
is frequently restored and maintained, provided detachment of 
the retina does not ultimately supervene from cicatricial con- 
traction at the seat of the rupture. On the other hand, a 
scotoma in the field may be produced, and if the rupture be 
in the region of the macula lutea, serious loss of sight may be 
caused. 

Treatment. — Careful protection of the eye, and abstinence 
from use of it, with dry cupping at the temple. 



3IO DISEASES OF THE EYE. 

New Growths of the Choroid. 

Sarcoma. — This is by far the most common neoplasm of 
the choroid, and is seen at all times of life, but most fre- 
quently between the ages of forty and sixty. When highly 
pigmented it is termed melanosarcoma. It may originate in 
any part of the choroid. 

If seen in a very early stage it is easily recognized from its 
projecting over the general surface of the fundus ; but unless 
it be in the region of the macula lutea it may not cause any 
serious disturbance of vision, and hence may not at that 
period be brought under the notice of the surgeon. 

The new growth soon gives rise to detachment of the retina 
by reason of serous exudation from the choroid ; and this is 
accompanied by opacity in the vitreous humor, which renders 
the diagnosis with the ophthalmoscope difficult or impossible. 
If the detachment be shallow and the retina translucent, the 
tumor may still sometimes be seen through the subretinal 
fluid by aid of strong illumination ; and even direct sunlight 
may be employed in some such cases. Owing to the great 
defect of vision which comes on in this stage, we very com- 
monly see these cases then for the first time. The history of 
the case may aid us ; and the absence of the more usual causes 
of detachment of the retina should make us suspicious of an 
intraocular tumor. 

Soon the intraocular tension increases ; and this makes the 
diagnosis again more easy in many cases, for the combination 
of detached retina and increased tension exists only with intra- 
ocular tumors. The increased tension may come on very 
slowly, and without ciliary neuralgia ; or more rapidly, and 
with all the signs and symptoms of acute glaucoma. Still, ii 
the case come now under observation for the first time, the 
diagnosis may be by no means easy should the refracting 
media be opaque (as always in acute glaucoma), and conse- 



THE CHOROID. 311 

quently the detachment of the retina be concealed from view. 
Here, again, the history of the case is all we have to depend 
on ; especially the fact of the patient having noticed a defect 
at one side of his field of vision previous to the onset of 
glaucoma. 

In the next stage of the growth it perforates the cornea or 
sclerotic, and, increasing rapidly in size, although still covered 
with conjunctiva, it pushes the eyeball to one side, the upper 
lid being stretched tightly over the whole. On raising the lid 
the tumor is seen as a bluish-gray mass of irregular surface. 
The conjunctiva is now soon perforated, and the surface of the 
tumor becomes ulcerated, with a foul-smelling discharge and 
occasional hemorrhages. The tumor gradualh' invades the 
surrounding skin and the bones of the orbit, and by extending 
through the sphenoid fissure and optic foramen reaches the 
base of the brain. 

It is usually upon the neighboring tissues of the eyeball be- 
coming involved that secondary growths begin to form in other 
organs, the one most prone to be affected being the liver. The 
lungs, stomach, peritoneum, spleen, and kidneys may all be 
attacked. 

Choroid sarcoma is almost always primary, but it has been 
seen a few times as a metastatic disease. 

The entire progress of such a growth varies considerably. 
It may occupy but a few months, or it may extend over many 
years. 

Carcinoma. — This is extremely rare, and the cases of it on 
record were all of metastatic origin, the primary disease being 
in the breast. It is not possible to distinguish choroid sar- 
coma from choroid carcinoma by the ophthalmoscope. 

Tubercle is sometimes seen in cases of acute miliar}^ tuber- 
culosis as round, slightly prominent, pale yellowish spots, of 
sizes varying from 0.5 to 2.5 mm. in diameter, situated always 
in the neighborhood of the optic papilla and macula lutea, and 



312 DISEASES OF THE EYE. 

unaccompanied by pigmentary or other choroid changes. 
There may be but one of these tubercles, or there may be many 
of them. They occur, as a rule, in a last stage of the general 
disease, but have occasionally been noted long before its 
appearance. In obscure cases of the general disease, the oph- 
thalmoscope has sometimes rendered valuable diagnostic aid 
by discovering these minute tubercles in the choroid. 

Very rarely a tubercular tumor grows in the choroid in cases 
of general chronic tuberculosis, and attains a large size, the 
growth destroying the eye similarly as sarcoma or carcinoma. 
In young children it may be impossible to diagnose between a 
tubercular tumor of the choroid and a glioma of the retina 
(Chap. xv). Yet, as in either case enucleation is indicated, the 
diagnosis is not of much practical importance. 

Other, but rare forms of tumor of the choroid are : 

Sarcoma carcinomatosum^'^ and, in a case of my own, osteo- 
sarcoma.^ 

Treatment. — So long as, in cases of sarcoma and carcinoma, 
the tumor is wholly intraocular, enucleation of the eyeball 
should be performed, and may be done with fair hopes of 
saving the patient's life, if the disease be primary. When the 
orbital tissues have become involved, extirpation of all the con- 
tents of the orbit, and even, if necessary, removal of portions 
of its bony walls, ought to be undertaken, should the general 
health permit, in order to rid the patient of his loathsome 
disease ; although the probable presence of secondary growths 
elsewhere renders but small the prospect of saving the patient's 
life. 

Cases of miliapy choroid tubercle do not call for direct 
treatment. In cases of tubercular tumor the question of re- 



'^^ Von Graefe's Archiv, x, pt. i, p. 179; Landsberg, Archiv f. Ophthal. 
xi, pt. i, p. 58; Trans. Acad. Med. in Ireland, i, p. 47. 
\ Bericht der Heidelberger Ophthal. Gesellsch., 1%%-}^. 



THE CHOROID. 313 

moval of the eyeball must depend upon the general state of 
the patient ; but if it seem probable that life will be prolonged 
until after the ocular growth has become extraocular, removal 
of the eye should be recommended. 

Congenital Defects of the Choroid. 

Coloboma. — This is a solution of continuity occurring 
always in the lower part of the choroid, and usually associated 
with a similar defect in the iris. It may commence at the 
optic papilla, and involve the ciliary body also, and even the 
crystalline lens may have a corresponding notch ; or it may 
not extend so far in either direction. The condition is recog- 
nized ophthalmoscopically by the white patch, due to exposure 
of the sclerotic where the choroid is deficient. Sometimes the 
retina is absent over the defect in the choroid, a circumstance 
which may be ascertained by the arrangement of the retinal 
vessels ; but even if it be present, its functions at that place are 
wanting, and a defect in the field of vision exists. Central 
vision is often normal. 

Albinism, or the want of pigment in the choroid and iris. 
— This is usually accompanied by defective pigmentation of the 
hair of the body. The iris has a pink appearance, due to re- 
flection of light from its blood-vessels, and from those of the 
choroid, and with the ophthalmoscope the latter vessels can 
be seen down to their finest branchings. The light, not 
being partially absorbed by pigment, causes the patient much 
dazzling, and high degrees of the condition are usually ac- 
companied by nystagmus. In childhood, the albinism and 
attendant symptoms are more marked than later on, when 
some degree of pigmentation usually takes place. 

Much advantage may be derived in many of these cases by 
the use of stenopeic spectacles, at least for near work. Any 
defect of refraction should be carefully corrected, in order to 
give the patients the best possible use of their eyes. 



314 DISEASES OF THE EYE. 

Sympathetic Ophthalmitis. 

By this term we understand a uveitis (iridocyclitis, irido- 
choroiditis) caused by an iridocyclitis of the other eye, the 
latter being usually of traumatic origin. 

The affection owes its name to the theory, held until a few 
years ago, that it was due to reflex action of the ciliary nerves. 
Although this view, which is no longer in accord with modern 
pathology, has given place to another, yet the original name 
of the disease is still retained, and we often speak of the in- 
jured eye as the exciting eye, while the secondarily affected 
eye is called the sympathizing eye. 

The cyclitis most likely to cause sympathetic ophthalmitis 
is that set up by a punctured wound of the eyeball, especially 
a wound involving the ciliary body. The cyclitis set up by 
a foreign body, which pierces the tunics of the eye and lodges 
in its interior, is also of serious import, even though the ciliary 
body may not have been injured. Perforating corneal ulcers, 
and even simple incisions of the cornea, may form the starting 
point of sympathetic ophthalmitis. It is an important and in- 
teresting fact that eyes which are, or have been, the subject 
of purulent panophthalmitis do not give rise to sympathetic 
ophthalmitis. 

There is considerable doubt as to whether sympathetic 
ophthalmitis can occur without a perforating lesion of the 
exciting eye. The only instances in which it appears really to 
have thus occurred are cases of choroid sarcoma in which 
there was iridocyclitis. It has been held that a dislocated 
crystalline lens, or cyclitis caused by a blow on the eye, could 
serve as excitants of sympathetic ophthalmitis ; but it such 
cases do occur they are very rare. I have myself never seen 
an instance of the kind. 

In cases of sympathetic ophthalmitis, the cyclitis of the 
exciting eye may be but slight, so slight indeed that vision is 



SYMPATHETIC OPHTHALMITIS. ,115 

not seriously affected ; or it may be severe. The degree of 
severity of the attack in the sympathizing eye does not depend 
on that of the inflammation in the exciting eye ; for in many 
cases the process in the sympathizing eye is a more severe one 
and more destructive to sight than that in the exciting eye. 

Sympathetic ophthalmitis is met with in persons of every time 
of life, but children under the age of puberty are more prone 
to it than in later years. 

Sympathetic irritation, or nnwosis, is a condition of the 
second eye sometimes seen, and which must not be confounded 
with sympathetic ophthalmitis ; nor is it to be regarded as a 
premonitory sign of the latter, for it may pass away without 
leaving any organic changes behind it. It consists in photo- 
phobia, lacrimation, pericorneal injection, and accommodative 
asthenopia, and is very probably a reflex neurosis. 

Premonitory Sign of Sympatlietic Ophtliahnitis. — Shrinking 
pain (the patient draws back his head in a most characteristic 
way) on pressure of the ciliary region of the exciting eye is 
almost always present where sympathetic ophthalmitis super- 
venes ; although it does not necessarily indicate that the latter 
is imminent, nor even that its ultimate appearance is certain. 
But there are no premonitory signs in the sympathizing eye 
prior to the attack of inflammation in it. 

Progress of Sympatlietic OpJitlialmitis. — Slight optic neuritis 
has been noticed in the sympathizing eye in some cases prior 
to or simultaneously with the outbreak of iridocyclitis, and 
is probably of tolerably constant occurrence. But it is not 
the sign or symptom which commonly first attracts the atten- 
tion of the patient or of the surgeon. The process is usually 
first observed in the sympathizing eye as a serous iridocyclitis, 
with increased depth of the anterior chamber and keratitis 
punctata, and may maintain this character to the end. As a rule, 
it soon passes over to a plastic form, with development of new 
vessels in the iris and shallowness of the anterior chamber. 



3i6 DISEASES OF THE EYE. 

The tissue of the iris and ciHary body becomes infiltrated with 
lymph-cells, and on their posterior surfaces and in the pupil a 
deposit of lymph-cells takes place, the choroid also becoming 
similarly infiltrated, and connective tissue is developed in its 
exudation. The vessels of the uveal tract are destroyed by 
pressure of the newly-developed connective tissue ; the vitreous 
humor consequently shrinks, causing detachment of the retina, 
cataract, and phthisis bulbi. 

Or the process may be confined chiefly to the anterior seg- 
ment of the eyeball, the iris, ciliary body, and lens, and may 
merely cause disorganization of those parts with shallow an- 
terior chamber — a condition known as phthisis anterior — 
while the vitreous humor, retina, and choroid remain healthy. 
In such cases, of course, vision is much damaged. Or, ae^ain, 
very occasionally, in some mild cases, the exudation may be- 
come absorbed, and leave a tolerably clear pupil and media, 
with more or less useful sight. 

The shortest period at which, after iridocyclitis has been 
set up in the injured eye, sympathetic ophthalmitis is liable to 
appear seems to be about twelve or fourteen days, and the 
longest about twenty years. The most usual interval is from 
six to eight weeks. 

Nature of the Disease. — Investigations made in recent 
years,* especially those of Deutschmann, render it extremely 
probable that sympathetic ophthalmitis is an inflammation due 



-^Knies, Sitzungsber. d. Ophth. Geselhch, 1879, p. 52; Leber, A. von 
Graefe' s Archiv, xxvii, pt. i, p. 325 ; Brailey, Trans. Iniernat. Med. Con- 
gress, 1881, Vol. iii; Snellen, Trans. Internat. Med. Congress, 1881, Vol. 
iii ; Macgillivray, Amsterdam Interjiat. Med. Congress, 1879 ; Berlin, Volk- 
mann' s Samml. Klin. Vortrdge, No. 185, 1880; Deutschmann, y^. z-wz Graefe' s 
Archiv, xxx, pt. iii, p. 77 ; xxxi, pt. ii, p. 277, and " Ueber die Ophthalnoia Mi- 
gratoria," 1889 ; Gifford, Archives of Ophthalmology, 1886, p. 281. Randolph, 
in Ai'ch. of Ophthal., Vol. xvii, p. 188, does not support the theory of extension 
of the process through the optic nerves and chiasma, but he does not offer an 
alternative explanation. 



SYMPATHETIC OPHTHALMITIS. 317 

to microorganisms, and propagated by them to the sympa- 
thizing eye by direct continuity through the optic nerves and 
chiasma from the exciting eye, as erysipelas extends over the 
skin. A great many objections have of late been raised 
against the migratory theory of the disease, but they have 
been satisfactorily disposed of by Deutschmann * in a new 
work on the subject. The staphylococcus pyogenes is the 
microbe which has been experimented with, and it has also 
been found in eyes which have given rise to sympathetic 
ophthalmia ; but it is true that the real microorganism en- 
gaged has not yet been discovered. 

Prognosis. — This disease is one of the most serious to which 
the eye is liable, leading as it does, in the vast majority of 
cases, to absolute and incurable blindness. It is but rarely 
that the sympathizing eye escapes with some useful vision. 

Treatment. — The most important point is the prevention of 
the extension of the inflammation to the other eye. Sir W. 
Bowman f found it possible in private practice, by careful 
nursing for a year or more, to save some eyes with severe 
wounds, and to prevent the occurrence of sympathetic 
ophthalmitis. 

Abadie recommends \ that, when the case comes under 
treatment early, antiseptic measures be taken to prevent in- 
fection, the best being subconjunctival injections of corrosive 
sublimate (see Chap, vi) ; and that, if these fail, the actual 
cautery be applied to the wound ; and that, if this be not 
enough, one or two drops of a i : looo or i : 500 solution 
of sublimate be injected into the wounded eye ; and, where the 
second eye has become affected, one or two drops of the same 

* Beitrage f. Augenheilk., March, 1893. Schirmer, von Graefe'' s Archiv, 
xxxviii, pt. iv, p. 93. This is an exhaustive article, and contains a bibliography of 
nearly 300 papers. 

t Ophthal. Rev., 1882, p. 288. 

XA7inales d' Oculistique, March, April, 1890. 



3i8 DISEASES OF THE EYE. 

solution be injected into the vitreous humor of that eye.* He 
has found these injections of use in checking or amehorating 
sympathetic ophthalmitis. 

But the only measures generally admitted to be certain 
prophylactics, when employed in time, and the only ones 
applicable to the great mass of those with whom we have to 
deal, are removal of the injured eye, evisceration, and Mules' 
operation, and a most difficult question sometimes presents 
itself when, in a given case, we have to decide as to the ne- 
cessity for one of these measures. The following rules guide 
me in my own practice : 

1. Although danger to the second eye practically does not 
arise until inflammation has been set up in the exciting eye,t 
yet I would perform primary enucleation, evisceration, or 
Mules' operation on the latter if it had been so injured as to 
make recovery of sight almost hopeless and the onset of irido- 
cyclitis in it almost certain. 

2. I would enucleate J in the same case were iridocyclitis 
already set up in the injured eye. 

3. I would enucleate in a case of iridocyclitis where a 
foreign body, which could not be safely extracted, was present 
in the eye, even though the vision were fairly good ; because 
we know that here the danger of sympathetic ophthalmitis 
amounts almost to a certainty. 

4. I would enucleate in a case of acute iridocyclitis, trauma- 
tic or idiopathic, where vision was lost, especially if the eye 

^ Berry {Trans. Ophthal. Soc. Un. King., 1893, p. 220) finds that injections 
of chlorin water are better tolerated by the retina and vitreous, and tliat they 
prevent purulent hyalitis after inoculation of the vitreous with pus. De 
Schweinitz [Joiirn. of Ainerican Med. Assoc, October, 1893) made experiments 
on rabbits with unsatisfactory results. 

"j" A few cases are recorded in which, although the exciting eye was removed 
almost immediately after the injury, yet sympathetic ophthalmitis supervened. 

X For the sake of brevity, the word enucleation only is used in what follows, 
but evisceration or Mules' operation is equally implied. 



SYMPATHETIC OPHTHALMITIS. 319 

were tender on pressure ; for here the eyeball is useless and 
disfiguring, and apt to be a source of danger to its fellow. 

5. I would enucleate in a case of phthisis bulbi, even of old 
standing, where there was shrinking pain on pressure, for the 
same reasons as in No. 4. 

6. I would enucleate in a case where the sympathizing eye 
is already affected, provided vision in the exciting eye be lost, 
and hopes of its recovery but slight, if any ; for improvement 
in the sympathizing eye or a greater amenability of it to treat- 
ment has been frequently observed after this has been done. 

7. I would enucleate in a case of sympathetic irritation if 
the sight of the exciting eye were very defective and the neu- 
rosis very persistent. 

a. I would not remove any injured eye, unless it contained 
a foreign body which I could not extract, if its sight were fairly 
good and as yet no sign of inflammation present. For inflam- 
mation may not come on, and the eye may possibly be saved. 

b. I would not enucleate the exciting eye, if sympathetic 
ophthalmitis had already appeared, should the vision of the 
exciting eye be fairly good. (Contrast this with Rule 6.) For 
it often occurs that the process in the sympathizing eye is not 
arrested by the proceeding, and that where the latter is not 
undertaken, the exciting eye turns out in the end to be the 
organ with the better vision. 

Cases have been observed in which sympathetic ophthalmi- 
tis broke out some days after removal of the exciting eye. In 
these instances, the inflammation no doubt had already started 
on its journey from the exciting eye, the removal of which 
did not arrest its progress. Inasmuch, then, as the inflamma- 
tion takes some twelve to fourteen days {z'ide supra) to 
travel from one eye to the other, one cannot feel certain of 
having averted sympathetic ophthalmitis before that period at 
least has elapsed after enucleation of the exciter ; and it is well 
to impose abstinence from use of the eye, or exposure of it to 



320 DISEASES OF THE EYE. 

much light, for that time, or longer. This fact is not to deter 
the surgeon from recommending enucleation when indicated ; 
for in the vast majority of cases it has the desired effect, and 
even in the cases where sympathetic ophthalmitis was not 
averted, the inflammation in the sympathizer was usually of a 
mild type and yielded to treatment. 

As substitutes for enucleation of the eyeball in these cases, 
division of the optic nerve in the orbit (optic neurotomy), re- 
section of a piece of the optic nerve in the orbit (optic neurec- 
tomy), and evisceration or exenteration of the eyeball have all 
been proposed and practised. 

Optic neurotomy is still employed by some surgeons ; but 
by most it has been abandoned, under the impression that it 
does not afford good protection against sympathetic ophthal- 
mitis, for the cut ends of the nerves reunite, and at least one 
case * has been observed in which several months after the 
optic neurotomy sympathetic ophthalmitis appeared. 

Optic neurectomy was first advocated by Schweigger,t and 
is, in his opinion, a better protective than enucleation. The 
views of other surgeons have not yet been published, and I 
have myself too little experience of the method to form an 
opinion of it. 

Evisceration is still on its trial as a prophylactic measure 
for sympathetic ophthalmitis. A few cases J are on record 
in which the good eye became affected not long after evis- 
ceration of the exciting eye, but this has taken place, too, as 
above stated, after enucleation ; and, so far as we can yet form 
an opinion, the prophylactic value of evisceration is at least 
as great as that of enucleation. The mode of performing the 
operation, and Mr. Mules' modification of it, are given at 

^ Leber, A. von Graefe" s Archiv, xxvii, pt. i, p. 339. 

■f" Archives of Ophthalmology, xiv, p. 223. 

X By F. R. Cross, Proceed. Ophthal. Soc, July, 1887. 



SYMPATHETIC OPHTHALMITIS. 321 

pages 196 and 197. The indications for these various pro- 
cedures are the same as for enucleation. 

Sympathetic ophthahiiitis having broken out, and the ques- 
tion of enucleation or other prophylactic measure having been 
decided in one sense or the other, the means to be directed 
against the process in the sympathizing eye have to be con- 
sidered. The patient should be confined for a lengthened 
period to a dark room, and atropin used for the eye ; while 
the general system is maintained by a tonic but non-stimulat- 
ing treatment. It is doubtful whether other means are of 
much value. Mercurialization is employed by some surgeons 
in these cases, but its value is problematic. 

No operation should be undertaken for the formation of an 
artificial pupil in the sympathizing eye until the inflammatory 
process has completely subsided, the tension of the eye 
improved, and the vascularity of the iris diminished. This 
period is, at the least, from twelve to eighteen months after 
the onset of the disease. If operative interference be resorted 
to during that period, the result is an aggravation or rekindling 
of the inflammation, with closure of the artificial pupil which 
may have been made, in consequence of proliferation of the 
layer of retroiritic connective tissue. Not even if the eyeball 
become of glaucomatous hardness, as sometimes happens, 
should the surgeon be tempted to operate. This is a golden 
rule. 

Of the operations employed for the establishment of an 
artificial pupil in an e\-e which has suffered from sympathetic 
ophthalmitis resulting in anterior phthisis, iridectomy most 
naturally suggests itself, and is the least satisfactory. The 
reason of this is that, owing to its ver\' disorganized state, 
the iris tears when drawn on by the forceps, and hence the 
formation of a satisfactory coloboma is almost impossible ; 
and even if this be obtained it is extremely liable to close 
21 



322 DISEASES OF THE EYE. 

again, from proliferation of the retroiritic connective tissue set 
going anew by the irritation of the operation. Yet sometimes 
after repeated iridectomies a permanently clear pupil may be 
obtained. 

Von Graefe operated by making a peripheral linear incision 
as for cataract, but passed the knife behind the iris, and in 
doing so he opened the capsule of the lens. An iridectomy 
is then made by seizing a wide portion of the iris and cor- 
responding retroiritic connective tissue with special forceps, 
one blade of which is passed behind these structures, whilst 
the other enters the anterior chamber, and then the iris, etc., 
having been drawn out, the exposed portion is cut off. The 
partially or completely opaque lens, or a considerable portion 
of it, becomes evacuated during this proceeding ; or, if not, the 
usual measures are taken to extract it. With this method, 
also, the pupil frequently closes again, and even more than 
one supplementary iridectomy or iridotomy (see Chap, xiii) 
may be required, but must not be undertaken until all irrita- 
tion subsides. The iridectomy, as above described, is now 
with advantage often replaced by a V-shaped one, made with 
de Wecker's forceps-scissors. 

The late Mr. George Critchett's method for the formation 
of a pupil in certain of these cases consists in passing a 
discission needle, by a boring motion, through the lenticular 
capsule ; another needle is then passed in close to the first, 
and then, by separating one point from the other, a rent is 
made in the center. This is followed generally by the escape 
into the anterior chamber of a small quantity of cheesy lens 
matter ; the latter is allowed to become gradually absorbed, 
and in the course of some weeks the capsule closes again. 
The operation has to be repeated several times before a 
clear pupil is obtained, care being taken that all irritation from 
the previous operation has subsided before another is under- 
taken. 



SYMPATHETIC OPHTHALMITIS. 323 

Mode of Performing Enucleation of the Eyeball. — There are 
two chief methods : 

1. Bonne fs Method. — The speculum having been inserted, 
an incision is made in the conjunctiva all around the cornea, 
and about six mm. removed from the latter. The bulbar con- 
junctiva is separated from the globe freely in all directions with 
scissors. With a strabismus hook each orbital muscle is 
caught up, and its tendon divided close to the sclerotic. The 
globe can now often be dislocated forward by pressure of the 
wire speculum, or of the margins of the Hds backward, and is 
then held in the fingers of the left hand, while the optic nerve 
is divided with strong scissors passed into the orbit from the 
median side. If the globe cannot be dislocated it may be 
draw^n forward with strong toothed forceps, while the nerve 
is being divided. 

2. The Vienna Method. — The only instruments used in this 
operation, in addition to the speculum, are strong, straight 
scissors and a strong toothed forceps. The tendon of the in- 
ternal rectus at its insertion, with the overlying conjunctiva, is 
seized in one grasp with the forceps, and so held until the 
conclusion of the operation. Immediately behind the forceps 
the tendon is divided with the scissors ; and now the forceps 
is holding merely the stump of the tendon adherent to the 
globe. Through the opening necessarily made at the same 
time in the conjunctiva one blade of the scissors is passed, and 
pushed on under the tendon of the inferior rectus muscle, 
w^hich is then divided along with the overlying conjuncti\'a. 
In the same w^ay the superior rectus is divided. The globe is 
now drawn well forward and rotated outward, the scissors 
passed into the orbit, the optic nerve felt for and divided. 
With one or two strokes of the scissors the external rectus and 
the two obliques are divided close to the globe, and the opera- 
tion is completed. This method is very rapid. It is not 
suited to any globe of which the w^alls are weak (fresh per- 



324 DISEASES OF THE EYE. 

fo rating injury, extreme staphyloma, etc.), for a good deal of 
pressure is exercised on the eyeball during its performance. 

Careful antiseptic precautions are to be employed in connec- 
tion with enucleation of the globe. Of these, I think the 
most important is the use of a full stream of corrosive subli- 
mate solution (i : 5000) into the cavity of the orbit as soon as 
the eyeball is removed, the irrigation being maintained for 
several minutes. The interior of the orbit is to be then well 
covered with finely-powdered boric acid, and a wood-wool or 
other antiseptic pad applied with a bandage. The orbit should 
be similarly dressed every twenty-four hours. 

I have never seen the slightest trouble after enucleation of 
the eyeball, but some cases of meningitis following upon the 
operation, and which have proved fatal, are reported. There 
can be no reasonable doubt but that in these instances septic 
matter made its way along the lymphatics of the optic nerve 
to the meninges, and that this septic matter w^as introduced 
upon the instruments, or escaped, in purulent cases, from the 
interior of the eyeball. Hence the very great importance of 
the careful antiseptic precautions above indicated. 

Occasionally, in ten days or longer after the operation, a 
granulation forms in the apex of the orbit, and requires to be 
snipped off. To prevent this, it is desirable to unite the con- 
junctival opening with a suture after the eyeball has been re- 
moved. 

An artificial eye can usually be inserted after a fortnight, 
but should not be constantly worn for a month at least, as 
until that period elapses it is liable to cause irritation and con- 
junctivitis. 

Mode of Perforining Resection of the Optic Nerve. — An open- 
ing is made into the conjunctiva about three mm. behind the 
insertion of the internal rectus muscle ; this nmscle is laid bare, 
and two curved blunt strabismus hooks are inserted beneath it. 
The hooks are drawn in opposite directions, so that one is 



SYMPATHETIC OPHTHALMITIS. 325 

caught in the angle of insertion of the tendon with a tendency 
to roll the eye outward, while the other will draw the muscle 
forward out of the orbit. Near the latter hook a catgut 
thread is passed through muscle and conjunctiva, first from 
within outward, and then the opposite way. The muscle is 
now divided at a distance of at least five mm. from its insertion 
into the sclerotic, and the ends of the catgut thread are tied 
in a knot. A second thread is passed through the terminal 
stump of the muscle, and similarly tied in a knot. The wound 
is now extended both toward the superior and inferior recti 
muscles ; and a small pointed double hook is inserted into the 
sclerotic far back, in order to draw the globe forward and 
outward. A pair of scissors, curved on the flat, are inserted 
alongside the globe, and the optic nerve cut through as near the 
optic foramen as possible. The posterior aspect of the globe 
can now be exposed to view by means of the double hook. 
The stump of the optic nerve remaining on the e\'eball is then 
cut off near its insertion into the sclerotic, the insertion of the 
oblique muscles divided, and the whole of the posterior circum- 
ference of the sclerotic bared by dissection. The eyeball is 
replaced, the wound closed by means of the catgut threads 
previously introduced, and as a precaution against sanguineous 
exophthalmos the eyelids are united by three sutures. 



CHAPTER XI. 

THE MOTIONS OF THE PUPIL IN HEALTH 
AND DISEASE. 

The size of the pupil in health depends chiefly on the intensity of the light 
to which the eye is exposed, contracting when light falls into the eye and dilat- 
ing in the shade. However defective vision may be, if quantitative perception of 
light remains, the reaction of the pupil as a rule takes place. 

There is no absolute standard for the physiologic size of the pupil. The 
latter varies in different healthy individuals, being in general smaller in elderly 
people than in youthful subjects ; for with increasing age the energy of the sym- 
pathetic — the dilating nerve of the iris — is reduced, while there is sclerosis of the 
walls of the vessels of the iris and rigidity of its stroma. Persons with blue 
irides have, in general, smaller pupils than those with dark eyes, for in them 
more light reaches the retina, and hence the pupil-reflex is stronger. It has also 
been stated that hypermetropic eyes are apt to have small pupils, owing to the 
constant effort of accommodation ; while in myopia, for the converse reason, the 
pupils are said to be wide. But the observation is not generally accepted. The 
diameter of the pupil when the accommodation is at rest has been found ■^ to 
vary between 2.44 and 5.82 mm., giving an average diameter of 4. I4 mm. 

Contraction of the Pupil. — Contraction to light is a reflex motion, the optic 
nerve being the afferent nerve, and the third nerve the efferent nerve innervating 
the sphincter pupillee. It has been shown by a high authority f that there are 
special afferent fibers in the optic nerve for the pupil-reflex, distinct from those 
for vision, and that it is possible to distinguish with the microscope these two 
kinds of nerve-fibers from each other. 

The anatomic investigations of Meynert % have shown that between the coipora 
quadrigemina and the center for the third nerve run communicating fibers (2 and 
2, Fig. 96), which probably enable this reflex to take place. Owing to the semi- 
decussation of the fibers in the optic chiasma, the stimulus of light, when applied 
to one eye alone, passes up each tract with equal power to the corpora quadri- 
gemina, and thence, by Meynert's fibers, to the center for the third nerve, or 
rather to that portion of it which acts as a special center for the sphincter pupillee, 

* Woinow, Ophthalvtometrie , Vienna, 1871. 

f B. von Gudden, Sitzungsber. d. Munch. Ges. /. Morphol. u. Physiol., 1886, i, p. i. 
X Vom Gehirn der Saugethiere, " Strieker's Handbuch," Leipzig, 1870. 

326 



THE PUPIL IN HEALTPI AND DISEASE. 



327 



and from that point down the myotic, or short ciliary, branches of this nerve to 
each ciliary ganglion, the ciliary nerves, and each sphincter iridis, causing as active 
a contraction of the pupil in the non-illuminated eye (consensual contraction) as 
in its fellow. It is probable, however,* that, in addition to this method of 
bringing about consensual contraction of the pupil, there is a communication, 
direct or indirect, between the centers for the third nerve of each side capable of 
effecting it. In no other way can the fact be explained that consensual contrac- 
tion of the pupil is maintained in cases of homonymous hemianopia. If, for 
instance (Fig. 96), there be a lesion of the right tractus opticus, giving rise to left 
hemianopia, the center of the left third nerve alone can be primarily stimulated ; 
but, as both pupils act, a communication between the centers of the third nerves 
must exist. Merkel f believes that 
there is a direct anastomosis between 
these centers. 

But it must be stated that there is a 
good deal of divergence of opinion as 
to the path by which the pupil-reflex 
is brought about. Bechterew is of 
opinion that the centripetal pupillary 
fibers pass uncrossed from the chiasma 
directly to the gray matter surround- 
ing the third ventricle, and thence 
backward to the pupillary nucleus of 
the oculomotor nerve of their own 
sides respectively. Gudden made 
experiments which seemed to him to 
prove that the corpora quadrigemina 
had nothing to do with this path, and 
ascribed to the external geniculate 
body the part usually assigned to the 
corpora quadrigemina. Mendel's ex- 
periments J would lead to the view 
that it is the ganglion habenulse which 
is the center for the pupillary reflex 

in animals, and in this he is largely supported by Darkschewitz, who holds that 
the pupillary fibers from the optic tract pass both into the pineal gland and the 
ganglion habenulae. According to Mendel, the reflex path would be : Optic 
nerve, optic tract, to the ganglion habenulae of the same side, thence by the pos- 
terior commissure to the nucleus of the third nerve, and thence to the ciliary 




3iV. Center of third nerve, i. Connection be- 
tween nuclei of third nerves. 2. IMeynert's 
fibers, ^. (.Corpora quadrigemina. C Chiasma. 
O. Optic nerve. P. Miotic fibers of third nerve. 
L. Seat of lesion. Arrows show path of im- 
pulse in lesion of right tract at L. 



* Leeser, Die Piipillarbewegung in Physiologischer und Pathologischer Beziehung, Wies- 
baden, 18S1, p. 14. |« Graefe-Saemisch Handbuch," Vol. i. 
I Neurolog. Centralbl., 1890, p. 184. 



328 DISEASES OF THE EYE. 

The reflex mobility of the pupil to light is tested most commonly for the pur- 
pose of deciding the existence or otherwise of posterior synechise. The next 
most comfnon object of the test, and the one with which we are here concerned, 
is to determine the sensitiveness to light of the retina or of the visual center. It 
affords generally a sufficient test of the presence or absence of quantitative per- 
ception of light ; but it must be remembered that the latter function may be 
wanting in certain diseased states, and yet the pupil-reflex takes place ; or the 
pupil-reflex may be wanting, and still perception of light be present. The test is 
best performed in diffuse daylight, with the patient's face directed toward the 
window, a distant object being looked at, and the eye which is not under ex- 
amination being carefully excluded from the light. The surgeon then, having 
observed the size of the pupil to be examined, excludes the eye from light with 
his hand for some moments. On removing the excluding hand, a normally react- 
ing pupil will be found to have become dilated ; and this dilatation, after an inter- 
val of about half a second, will be observed to give way to an extreme contrac- 
tion, which is maintained only for a moment, and is then succeeded by a moderate 
dilatation, and the pupil then again contracts somewhat, and so on, until, after 
some further minute oscillations, it comes to a standstill. The explanation for 
this phenomenon, which is termed hippus, is that each contraction of the pupil, 
by diminishing the supply of light to the retina, contains in itself the cause of the 
succeeding dilatation ; and, for the converse reason, each dilatation sets a going 
the succeeding contraction, until, at last, equilibrium is attained. A comparison 
between the maximum of dilatation and maximum of contraction, along with the 
promptness and rapidity with which the contraction takes place, enables the 
observer to form an estimate of the activity of the pupil-reflex. In performing 
this test, it is important that the patient's gaze should be fixed all through on a 
distant object — hence, unless where a mere trace of perception of light remains, 
the test used with the artificial light is not so reliable as that with daylight — so 
that the pupil-contraction which is associated with convergence or accommodation 
{vide infra) may not vitiate the experiment. The danger of a vitiation of the 
experiment by the reflex dilatation from the skin {znde infra) caused by the ex- 
cluding hand, is insignificant in practice. The consensual-reflex of the pupil, as 
well as the direct, should always be tested — one eye being alternately excluded 
and exposed, the motions of the pupil of the other eye are observed and compared 
with those of its fellow. In examining the pupils we have also to decide whether 
they are of equal size ; and in order to avoid error through posterior synechiee the 
comparison should be made, with both eyes open, successively in two very 
different brightnesses of light. Under normal conditions equality in size of the 
pupils will exist, not only with both eyes open, but also if one eye be shaded ; for 
the normal consensual pupil-reflex is equal to the direct reflex. If the pupils be 
found of different sizes, the least movable one is usually the pathologic pupil, but 
this is a question often difficult to decide. Finally, it should be noted w^hether the 
direct pupil-reflex is similar in all respects in each eye. 

In addition to the stimulus of light, the pupil-contracting center is excited by, 



THE PUPIL IN HEALTH AND DISEASE. 329 

or simultaneously with, the effort of accommodation for near vision. The object 
of this contraction is to cut off rays falling on the peripheral portions of the lens, 
which latter are not curved in the change for accommodation to the same degree 
as is the center of the lens. This contraction, however, is much more intimately 
connected with convergence of the visual lines than with the effort of accom- 
modation. It has been shown * that the contraction increases with the effort of 
accommodation, but not proportionately to the distance of the fixation point from 
the eye; and f that the pupils do not contract if accommodation be effected 
without convergence, but that in convergence without accommodation contraction 
is observed. It has also been found that the contraction was proportional to the 
degree of convergence, and that in myopes of high degree contraction of the 
pupil takes place at the other side of the far point, where, of course, the accom- 
modation does not come into play. Aubert J thinks there is probably a common 
center for the three actions, convergence, accommodation, and pupil-contraction 
— a view supported by Priestley Smith | ; and Hensen and Volckers || have found 
that in dogs, in the posterior part of the floor of the third ventricle, the centers 
for the branches to the ciliary muscle, the sphincter pupillse, and the rectus inter- 
nus occur in close succession, and they think that this region may be regarded as 
the center assumed by Aubert. The existence of such a center has been -placed 
beyond controversy by Eales' case ** of paralysis of convergence and accom- 
modation, and of the associated pupillary contraction. These three motions, 
then, are not dependent on each other, but are co-effects of one and the same 
cause — i. e. , a stimulus applied to the center for convergence, accommodation , 
and pupil-contraction. 

In examining the mobility of the pupils in a given case, the contraction on 
convergence should not be omitted. If the patient be blind of both eyes the 
observation can be made by calling on him to direct his eyes toward his own 
hand at about 12 inches' distance. If both accommodative contraction and light 
reflex are wanting, a lesion in the course of the centrifugal pupil fibers is indi- 
cated ; while, if the light reaction alone is wanting the lesion is in the course of 
the centripetal fibers. 

Dihitation of the Pupil. — The most reliable investigations ff have distinctly 
proved that there is no such muscle as the dilator pupillae. The dilatation of the 
pupil is in all probability largely the result of an inhibitory action of the sympa- 
thetic, a view maintained also by Gaskell %% and Jessop.^| The posterior limiting 
membrane of the iris is its only structure which is not thrown into folds when the 

* Adamiik and Woinow, Archiv fur Ophthalinologie, xvii, pt. i. 
t E. H. Weber, " De Motu iridis," Lipsiae, 1851. 

I " Graefe und Saemisch Handuuch," ii, p. 669. g Ophthal. Hosp. Rep., Vol. ix, p. 32. 

II Arch. /. OphthaL, xxiv, pt. i, p. 23. ** Trans. Ophthal. Sac, January jo, 1884. 
ft Schwalbe, " Handbuch der Sinnesorgane ; " Eversbusch, Bericht d. Ophtlial. Gese'lsch., 

1884; Y\xz\i%,CraeJe' s Archiv, xxxi, pt. iii, p. 39 ; Jessop, Proceed. Roy. Soc, 1886, p. 478. 
XXJourn. o/Phys., vii, i, p. 38. ^§ Proceed. Roy. Soc, 18S6, p. 484. 

28 



330 DISEASES OF THE EYE. 

pupil dilates (Fuchs) ; and therefore there can be little doubt but that it takes an 
active part in dilating the pupil, probably by reason of its elasticity. Yet, inas- 
much as when the pupil is dilated from paralysis of the third nerve, a further 
dilatation can be produced by atropin, it is probable that some other, as yet 
unascertained, dilating power resides in the iris. The mydriatic, or long ciliary 
nerves, originating (Hensen and Volckers) in the front part of the floor of the 
aqueduct of Sylvius, pass to a region in the lower cervical and upper dorsal 
portion of the cord, called by Budge* the ciiiospinal center; and from thence 
pass out with the two first dorsal nerves, and by way of the rami communicate 
to the sympatlietic in the neck; and tlience to the cavernous plexus, Gasserian 
ganglion, ophthalmic division of the fifth nerve, nasal branch of this division, 
ganglionic branch of this nerve, ciliary ganglion — there joined by more branches 
from the cavernous plexus — and from thence by the short ciliary nerves reach 
the eye. 

The dilating nerve-fibers are probably of twofold nature : muscular and vaso- 
motor. The experiments of Griinhagen, f Salkowski, J Bonders and Hamer, ^ 
Stellwag, II and J. Arlt, Jr., ■^'^ indicate this; and that the center for each kind 
of fiber is different, though both are situated in the medulla oblongata, and their 
fibers probably run the same course to the eye. The center for the muscular 
fibers is called the oculo-pupillary center. That the vasomotor fibers have a 
decided and independent influence in dilating the pupil has been shown by 
Rouget, ft Schoeler, J:|: and others. It is not certain what the mechanism of this 
influence may be, but it probably consists in a diminution in volume of the iris 
from anemia caused by contraction of the muscular coat of the vessels. 

Langley and Anderson ^^ find that stimulation of the cervical sympathetic 
causes dilatation of the pupil before the vessels of the iris contract, and that 
stimulation of a portion of the iris can produce a displacement of the pupil 
toward the side stimulated without relaxation of the sphincter. They assume, 
therefore, that there must be some radial contractile substance in the iris, but in 
what form they do not say. 

While light is the only stimulus capable of bringing about a reflex contraction 
of the pupil, the pupil-dilating center reacts to every sensitive stimulus; e. g., the 
prick of a pin or a pinch on the neck, galvanism applied to the leg,|||| the tickling 
of a sensitive place in the region of the fifth nerve on the face,*** etc. ; and 

* Ueber die Bewegungen der Iris, 1855. 

t Zeitschriftf. rat. Med., xxviii, and Archivf. d. Gesam. Physiol , Bd. liii. 

J Ibid., xxix, p. 167. 

\Nederl. Tijdschr. 71. Geneesk., 1864. 

II Ueber Atropin, All. Wiener Med. Zeitung, 1872, p. 146. 
** Archill fur Ophthal., xv, i. 

ft Comptes rendiis ct Mem. de la Soc. de Biolcgie, 1856. 
X\ Experivtentelle Beitrdge zur Irnbeivegitng- : Inaiig. Diis. Dorpat, 1869. 

II Journal 0/ Physiology, 1892, Vol. xiii. No 6. 

III Arndt, Griesetiger' s Archil) f. Psych. ,\\. 

*** Hecker, Tageblatt der 45 Versam deutscher Naturforscher in Leipzig, 1872. 



THE PUPIL IN HEALTH AND DISEASE. 331 

Westphal* observed dilatation on shouting loudly into the ear of a person undei 
chloroform. Schiff and Foa f found that in curarized dogs and cats a dilatation 
took place on the application of every stimulus, not necessarily painful, applied 
to the nerves of common sensation in any part of the body. Indeed, it is not 
necessary in the human subject that the stimulation should produce any sensation, 
for stimulation of the skin of the affected side in hemianesthesia, as also in 
sleep and in coma, will find response in dilatation of the pupil. The center for 
this reflex is probably in the medulla oblongata, J but, inasmuch as it takes 
place if the cervical sympathetic be divided, | it is evident that all the dilating 
fibers do not run to the eye by way of the cervical sympathetic. Schiff || thinks 
it probable that the Gasserian ganglion receives pupil-dilating fibers from the 
sympathetic traversing the cavum tympani. 

Some psychic emotions produce dilatation of the pupil. The pupils of a cat in 
anger dilate, and those of a frightened child. In sleep, or when under the 
complete influence of an anesthetic, the pupils are contracted, for then all 
pyschic and sensitive stimuli are reduced to a minimum. Facts authorize the 
conclusion that the medium dilatation of the pupil in the healthy state depends 
chiefly on the intensity of these stimuli, habitually transmitted through the 
sympathetic. If in any individual they be slight, his pupil is contracted ; if 
intense, it is dilated. Arndt ** asserts that in delicate, nervous, excitable people 
the pupils are often much and habitually dilated. 

In addition to those already mentioned, there are causes for the dilatation of the 
pupil which can hardly be referred to simple reflex action, but which seem to be, 
like the contraction of the pupil on convergence of the visual lines, associated 
with those of other centers in the medulla oblongata, especially with those for 
respiration and uterine action. With every deep inspiration or expiration a con- 
siderable pupillary dilatation takes place, not identical with that slight dilatation 
occurring on each ordinary inspiration and depending on variation of blood press- 
ure, but due"}"! to simultaneous stimulation of the respiratory and pupil-dilating 
centers by retention of carbonic acid gas in the blood. Raehlmann and 
Witowski ++ have observed marked dilatation at the beginning of each labor pain, 
to be explained as an associated action of the neighboring centers for uterine 
movements and pupil-dilatation. 

Besides the normal pupillary motions described in the foregoing, and visible 
for the most part to the naked eye of the observer, there is a phenomenon of 
pupillary motion which is discoverable only by aid of a corneal microscope or loup, 
consisting in perpetual, but very minute and irregular, fluctuations in size of the 



* Virchoiv s Archiv, xxvii, p. 409. 

t " La piipilla come estesiomeiro." L' Imparziale, 1874. 

X Salkowski, loc. cit. 

\ Vulpian, Archiv de physiol., etc., de Brown-Sequard, January, 1874. 

Il " Untersuchungen zur Naturlehre," x, 1867, p. 423. 
** Archiv f. Psyrhiatrie, ii, p. 589. ff Schiff, loc. cit. 

XX Archiv /. Physiologie, 1878, p. no. 



332 DISEASES OF THE EYE. 

pupil. This hippus has been aptly termed by Laqueur"^ the unrest of the pupil, 
and is due to the ever-varying sensitive and psychic reflexes, which are thus 
constantly manifesting their influences on the pupil. 

The fifth nerve has been held by some to have an influence over the motions 
of the iris, similar to that of the sympathetic. This is, according to Leeser, a 
mistaken view f ; the effect on the pupil following section of the fifth within the 
cranium being due to paralysis of the sympathetic fibers contained in it, and not 
to the lesion of the proper fibers of the fifth nerve. But Spallita and Consiglio % 
found, after removal of the superior cervical ganglion of the sympathetic, and 
when sufficient time for degeneration had been allowed to elapse, that stimulation 
of the fifth nerve caused miosis. Others, \ again, have ascribed to the fifth nerve 
a direct influence over the contraction of the pupil ; but this is to be regarded as 
a reflex action merely, Merkel, indeed, having demonstrated || the existence of a 
direct fibrillar connection between the centers of the fifth and third nerves. 

Action of the Mydriatics on the Pupil. Atropin. — Inasmuch as a 
maximum mydriasis can only result from paralysis of the pupillary branches of 
the third nerve, combined with excitation of the pupillary branches of the sym- 
pathetic, and as atropin effects such a mydriasis, it is evident that it acts in the 
way indicated on these nerves.'^* A. von Graefe proved ff that the aqueous 
humor of an eye into which atropin has been instilled acts as a mydriatic when 
applied to another eye. Duboisin, hyoscyamin, scopolainin, and daturin act 
similarly to atropin. Cocain mydriasis seems %% to be induced merely by a local 
irritation of the endings of the sympathetic in the iris, both of the vasoconstric- 
tor fibers and of the pupil-inhibitory fibers. Strychnin and curare are not, 
strictly speaking, mydriatics, as they only indirectly affect the pupil; the mydria- 
sis observed in poisoning by these drugs being, according to Schiff |^ and others, 
the result of the retention in the blood of carbonic acid gas. 

Action of the Miotics on the Pupil. Eserin (or Physostigniiii). — This 
drug is in all respects a complete antagonist of atropin, |||| paralyzing the peripheral 
endings of the sympathetic in the iris, and stimulating the endings of the branch 
of the third nerve in the sphincter pupillae. Pilocarpin and muscarin act similarly, 
but not with the same energy. NicotUi applied to the eye is found to act like 
eserin.*^" Morphin has an antagonistic efiect to atropin, both as regards the 



* Klin. Monaisbl. /. Augenheilk., December, 1887. f Leeser, loc. cit., pp. 46-48. 

X Archivio de Otlahnologia, 183, Vol. i. 

3 Griinhagen, Berl. Klin. Wochenschr., 1866, No. 24; Rogow, Zeitschr. f. rat. Med., 
Vol. xxix, p. 289. II " Graefe und Saemisch's Handbuch," i, p. 140. 

** Hermann, " Lehrb. der exp. Toxicologie," 1874. 
tt Archiv f. Ophthal. \, pt. i, p. 462, foot-note. 
\\ Jessop, Proceed. Roy. Sac, p. 441, 1885. 
gg P/lu^er's Archiv, 1871, p. 229. 

nil Harnack, Arch./, exp. Pathol., ii, p. 307; A. Weber, Archiv/. Ophthal., xxii, pt. ii, 
p. 231. 

*** Rogow, Zeitschri/t / rat. Med., xxix, p. i; Schur, Zeitschri/t / rat. Med., xxxi, 
p. 402. 



THE PUPIL IN HEALTH AND DISEASE. S33 

pupil and the general nervous system, and is employed in cases of poisoning by 
atropin {c'l'i/e p. 286). 

Chloroform in the first or excitation stage of anesthesia, according to the 
investigations of Westphal,"^ Budin,f and Hirschberg, J stimulates the pupil- 
dilating center, and in the second stage gradually reduces the excitability of this 
center, until, finally, it is completely paralyzed, so that no form of stimulation 
causes any dilatation. Following on this is a still further contraction to a pin- 
hole pupil, due to stimulation of the pupil-contracting center. Should the inhala- 
tion of the anesthetic be continued longer, a dilatation of the pupil, often sudden, 
takes place, and this indicates paralysis of the pupil-contracting center, and the 
most serious consequences for the life of the patient. 

The Size of the Pupil in Disease. — Miosis may be caused by a diseased 
process irritating the pupil-contracting center or nerve-fibers (the irritation miosis 
of Leeser), or by one causing paralysis of the pupil-dilating center or nerve-fibers 
(the paralytic miosis of Leeser), or by a combination of both. Either cause 
alone would produce a medium miosis ; a combination of the two would give a 
maximum miosis. 

Irritation miosis, according to Leeser, is not usually increased by the stimulus 
of light, nor on convergence of the visual axes, nor does it diminish in the shade. 
Mydriatics dilate such a pupil widely; miotics contract it ad maximum. In 
paralytic miosis the pupil reacts well to light and on convergence, but does not 
dilate on application of sensitive or psychic stimuli, or with coordinated motions. 
Mydriatics dilate such a pupil only partially, while miotics contract it ad maxi- 
mum. In maximum miosis every reaction is wanting, strong mydriatics alone 
producing a medium dilatation. 

Irritation miosis is found in : a. The early stages, at least, of all inflammatory 
affections of the brain and its meninges ; in simple, tubercular, and cerebrospinal 
meningitis. When in these diseases the medium miosis gives place to mydriasis, 
the change is a serious prognostic sign,§ indicating the stage of depression with 
paralysis of the third nerve, b. In cerebral apoplexy the pupil is at first contracted, 
according to Berthold,|| who points out that this contraction is a diagnostic sign 
between apoplexy and embolism, in which latter the pupil is unaltered, c. In 
the early stages of intracranial tumors situated at the origin of the third nerve or 
in its course, d. At the beginning of an hysteric or of an epileptic attack."^* 
e. In tobacco amblyopia, ff probably from stimulation of the pupil-contracting 
center by the nicotin. / In persons following certain trades, as the result of 
long-maintained effort of accommodation++ (watchmakers, jewelers, etc.), the pupil- 
contracting center being subject to an almost constant stimulus, g. As a reflex 



* Vircho-Ms Archiv, xxvii, p. 409. f Gazette des Hopiiaux, 1874, p. 910. 

X Bert. Klin. Wochenschr., 1876, p. 652. § Leeser. loc. cit., p. 82. 

II Berl. Klin Wochenschr., 1869, No. 39. 
** Wecker, " Graefe und Saemisch's Handbuch," iv. 
ft Hirschler.yircA./. Ophthal., xvii, pt. i. 
%\ SeiflFert, Allgem. Zeitschri/t/Ur Psyckiatrie, x, 1853, P- 544- 



334 DISEASES OF THE EYE. 

action in ciliary neurosis; consequently, in many diseased conditions of those 
parts of the eye supplied by the fifth nerve. 

Paralytic miosis occurs in spinal lesions above the dorsal vertebrae ; — ^.^., in- 
juries and inflammations, especially of the chronic form. The contracted pupil 
occurring in gray degeneration of the posterior columns of the spinal cord has 
been long known as spinal miosis. In the simple form of this miosis the pupil 
has but a medium contraction, and reacts both to light and on convergence. This 
condition is found in the early stages alone, when the disease has attacked merely 
the ciliospinal center, or higher up, as far as the medulla oblongata ; later on, 
when Meynert's fibers become engaged, we have the Argyll Robertson pupil. 
The very minute pupil, often seen in tabes dorsalis, is probably due to secondary 
contraction of the sphincter pupilloe.'^ 

Argyll Robertson was the first to point outf that in tabes dorsalis the pupil, 
although contracted, and responding to light by further contraction but slightly or 
not at all, does become more contracted on convergence of the visual axes (or ac- 
commodation). He explained this phenomenon as being due to paralysis of the 
ciliospinal nerves, which he therefore regarded as the nerves supplying the 
sphincter iridis. But Raehlmann points out if that the miosis and the motor phe- 
nomenon are not directly connected ; for it sometimes happens that pupils which 
do not react to light and do contract on convergence are not habitually contracted, 
and may even be somewhat dilated. The two symptoms are no doubt often pre- 
sent together in tabes. The miosis is a sign, and an important one, of disease of 
the posterior columns; while the defective reaction to light with retained contrac- 
tion on convergence indicates disease at some distance from the spinal cord. It 
has been held by some that the seat of this disease, causing the Argyll Robertson 
pupil, is in Meynert's fibers (2 and 2, Fig. 96) connecting the corpora quadri- 
gemina and the third nerve nuclei. But, as has been pointed out by Bevan Lewis, ^ 
while this explanation would answer were all instances of this symptom binocular, 
it cannot be the true one when, as we know, the symptom is sometimes unilateral ; 
for the intranuclear path (l. Fig. 96) between the nuclei of the two third nerves 
must exist in order to enable the consensual action of the pupils which takes place 
in lesions of one optic tract to be brought about. In the same way lesion of Mey- 
nert's fibers on one side would still permit of the pupillary reaction to light of each 
pupil. Bevan Lewis therefore concludes that the Argyll Robertson pupil is due to 
a nuclear lesion. Disease in Meynert's fibers (as also disease of the optic nerve), 
maybe in direct connection with disease of the cord, Stilling having found || fibers 
passing directly from the optic tract into the crus cerebri. 

Some authorities regard miosis as one of the earliest symptoms of tabes, while 
others do not. Raehlmann also thinks that, perception of light being present, if 



* Hempel, Arcliiv f. Ophthal., xxii, pt. i. 

\ Edin. Med. Journal, xiv, 1869, p. 669, and xv, 1870, p. 487. 

X Loc. cit ^ p. 7. \ Brit. Med. Joicrnal, April 25 and May 2, 1896. 

II Beilagehe/t zu Zehender' s Monatsbldtter , xvii, pp. 203-207. 



THE PUPIL IN HEALTH AND DISEASE. 335 

the pupils do not react to light, while they do contract on convergence, the symp- 
tom is usually one of serious central disease. 

Paralytic miosis is also found in general paralysis of the insane. In acute 
mania the pupil is usually much dilated ; and when this mydriasis is changed for 
miosis approaching general paralysis may be prognosticated.* Miosis following 
on irritation mydriasis is also found in myelitis of the cervical portion of the cord. 
In bulbar paralysis, if paralytic miosis occurs, the disease is probably complicated 
with progressive muscular atrophy or with sclerosis of the brain and spinal cord.f 

Hirschler slates j that he has frequently noticed a contracted pupil in alcoholic 
amblyopia, due, probably, to an affection of the medulla oblongata, possibly fatty 
degeneration. Miosis may also be due to paralysis of the cervical sympathetic, 
resulting from injury, from pressure of an aneurysm of the carotid, innominate, or 
aorta, or from pressure of enlarged lymphatic glands. In apoplexy of the Pons 
Varolii miosis is present, but it is not yet certain whether it is an irritation 
miosis I or a paralytic miosis. || 

Mydriasis may be caused by a diseased process giving rise to irritation of the 
pupil-dilating center or fibers, or by paralysis of the pupil-contracting center or 
fibers. 

The former is termed irritation (or spasmodic) mydriasis, and, according to 
Leeser, is characterized by a moderately dilated pupil, contracting somewhat to 
light and on convergence, but not dilating on sensitive or psychic stimuli ; easily 
dilated ad maximum by mydriatics, but with difficulty contracted ad maximum by 
miotics. The latter is called paralytic mydriasis, and in it there is a moderately 
dilated pupil, reacting to sensitive and psychic stimuli. The reaction to light 
and on convergence varies according to the seat of the lesion. If the lesion lie 
between the iris and the pupil-contracting center, the direct and consensual 
reaction to light is wanting, as also the associated motion on convergence of the 
visual lines. But if the lesion lie between the retina and the pupil-contracting 
center the direct contraction to light is wanting, while the consensual contraction 
and that on convergence are retained.^* In either case the pupil can be dilated 
ad maximum by mydriatics, but not contracted more than to medium size by 
miotics. 

Irritation of the pupil-dilating center and paralysis of the pupil-contracting 
center existing simultaneously give rise to maximum mydriasis. In it there is 
absolute immobility to stimuli of all kinds, except to strong miotics, which may 
bring the pupil back to the normal size. 



* Seiffert, loc. cit. f Leeser, loc. cit., p 94. 

X Archi?' /. Opiithal., xvii, pt. i, p. 229. 

\ Larcher, Pathol de la prAub. Annu/aire, deux, tirage, p. 54. 

II Jii.lell, Be>l. Klin. IVocheitsck., 1872, No. 24. 
** Heddaus (Knapp, Archiv f. Ophthal., xxvii, 1893, p. 38) and Turner {Royal London 
Ophthal. Hosfi. Rep., December, 1892) assume ihat the sphincter derives its nerve-fibers from 
two centers, viz. : from the special sphincter center, and aUo from the center for convergence 
or accommodation. 



336 DISEASES OF THE EYE. 

Irritation mydriasis occurs : a. In hyperemia of the cervical portion of the 
spinal cord and in spinal meningitis, b. In the early stages of new growths in 
the cervical portion of the cord. c. In cases of intracranial tumor and other 
diseases causing high intracranial pressure, according to Raehlmann, although 
Leeser points out that these may also give rise to paralytic mydriasis, d. In the 
spinal irritation of chlorotic or anemic people after severe illness, etc. e. As a 
premonitory sign of tabes dorsalis. f. In cases of intestinal worms, owing to the 
stimulation of the sensitive nerves of the bowel ; and sometimes in other forms 
of intestinal irritation, g. In psychic excitement ; e. g. , acute mania, melan- 
cholia, progressive paralysis of the insane (often then unilateral, with miosis in 
the other eye). 

Unilateral mydriasis occurring at short intervals, now in one eye and now in 
the other, is, according to von Graefe,* a premonitory sign of mental derange- 
ment. Von Graefe observed madness, in the form of manie des grandeurs, to 
come on some months after the occurrence of this symptom. 

Paralytic mydriasis (iridoplegia) may be due either to a paralysis of the pupil- 
contracting center or as the result of the stimulus not being conducted from 
the retina to that center. It may be found under the former circumstances : 
a. Sometimes in progressive paralysis, where at first there was miosis, b. In 
various diseased processes at the base of the brain affecting the center of the 
third nerve, c. In a late stage of thrombosis of the cavernous sinus. f d. In 
orbital processes which cause pressure on the ciliary nerves, e. In glaucoma. /. 
In cases of intraocular tumors which have attained a certain size. 

In paralytic mydriasis, due to non-transmission of the stimulus of light to a 
healthy pupil-contracting center and nerves, contraction of the pupil will take 
place only on convergence of the visual lines. The same condition of pupil will 
be found if the lesion lie in the course of Meynert's fibers, although vision may 
be normal. If the lesion lie in the center of vision, or in the course of the fibers 
connecting this center with the corpora quadrigemina, although absolute amaurosis 
exists, the reaction of the pupil to light will be perfect. Paralytic mydriasis, due 
to non-conduction of light stimulus, is found in most cases of optic atrophy. 

Bevan Lewis has pointed out J that the reflex dilatation on stimulating the skin 
is wanting in cases of general paralysis and of epilepsy to the extent of about 36 
per cent, in women and 43 per cent, in men. 

Damsch has noticed \ a marked increase of the hippus of the pupil in certain 
diseased states — namely, multiple sclerosis, acute meningitis, apoplectic attacks 
followed by secondary tremor and spasms of the paralyzed muscles, and in 
neurasthenia. He is inclined to liken the hippus in these cases to the increase of 



* Archiv f. Ophthal., iii, pt. iii, p. 350. 
f Knapp, Archiv f. Ophthal., xiv, pt. i, p. 220. 
X Brit, Med. Journ., April 25 and May 3, 1896. 

g Neurolog. Centralbl., 1890, p. 258 ; also Zeminski, alistract in Annales d' Oculist, Marchj 
1894, p. 239. 



THE PUPIL IN HEALTH AND DISEASE. 337 

the tendon reflexes, while immobility of the pupil would be the homologue of 
loss of tendon-reflex. Yet he does not think an exclusively reflex origin for the 
exaggerated hippus can be adopted in these cases, as it continues to an abnormal 
degree even when all reflex irritation is avoided ; and consequently he concludes 
that an increase of the physiologic hippus must be included as a cause. 

Forster* finds that in tabes dorsalis the oscillations of the pupil diminish in 
intensity, while the rhythm remains unaltered ; but that in progressive paralysis 
the rhythm is lost. When the pupil has lost its power of reaction to light, the 
hippus still continues for a while. 

* Versammlung deutscher Naturf u. Aerzte, Niirnberg, 1893 {Deutsch. Med. Wochenschr.). 



CHAPTER XII. 

GLAUCOMA.* 

The chief and essential symptom of this disease is increased 
intraocular tension — increased hardness of the eyeball — due 
to overfulness of the globe. 

There is primary glaucoma and secondary glaucoma. 

In primary glaucoma the increased tension comes on with- 
out any previous recognizable disease of the eye ; and it is 
with it we have mainly to do in this chapter. 

In secondary glaucoma the increased tension comes on in 
consequence of obvious antecedent disease in the eye. 

Primary Glaucoma. 

Of primary glaucoma there are two great kinds — the non- 
inflammatory, non-congestive, or chronic glaucoma ; and the 
inflammatory, congestive, or more or less acute glaucoma. 
In using the term inflammatory here it is not to be supposed 
that acute glaucoma is an inflammation in the strict patho- 
logic sense of the term, or, if so, to but a slight extent. 
The term is employed rather on account of some symptoms 
which are present (pain, redness of the e}'eball, lacrimation), 
and which we are wont to see with inflammations of the eye — 
symptoms which are wanting in chronic glaucoma. 

Increased intraocular tension, then, is the chief and essential 



* From yXavKog, sea-green. The name was given to the disease by the old 
writers, on account of the greenish reflection obtained from the pupil in some 
cases. But this greenish reflection is seen in other diseased conditions, and 
therefore is not characteristic of glaucoma. 

338 



GLAUCOMA. 339 

symptom of glaucoma, whatever form of it may come before 
us ; although this increased tension may not be present in the 
same degree, or indeed at all, at every time. 

If the surgeon place the tips of his index fingers close 
together on a normal eyeball, and make gentle pressure with 
them alternatel}-, he will observe that the eyeball pits sHghtly 
on this pressure, and that a sensation of fluctuation is given 
to the fingers. The amount of this pitting or fluctuation 
varies according to the degree to which the eyeball is filled 
with its humors, and also, to some extent, according to the 
thickness of the sclerotic coat, and is not precisely the same 
in every normal eye. The glaucomatous eyeball is felt to be 
more resistent, to be harder, than the normal globe. 

But there are e}-es which have normally a low tension ; i. e., 
below the average normal tension ; and others which have a 
tension somewhat abo\"e the average normal tension ; and in 
eyes of the latter class it is occasionally difficult to decide 
whether or not the tension is abnormally high, especially if 
there happen to be symptoms which might be due to high 
tension. If it be a question of one eye only, then a com- 
parison of its tension with that of its fellow decides the matter, 
for the physiologic tension is always the same in each eye. 

Some clinical experience is necessary before the surgeon 
can appreciate by palpation those degrees of tension which 
are just abo\-e or just below the normal ; and no other 
method is equally satisfactor\'. Tonometers have indeed been 
invented for the purpose, but for ordinary use the educated 
fingers are to be preferred. 

For the purposes of clinical notation Sir \V. Bowman sug- 
gested some signs, which have been very generally adopted. 
Xormal tension is indicated bv the letter T. sho-ht increase of 
tension = T — i, still higher tension = T -f 2, while T + 
3 indicates stony hardness of the eyeball. In the same way 
diminished tension is T — i, T — 2. and T — 3. T — ? 



340 



DISEASES OF THE EYE. 



and T — ? indicate that it is doubtful whether the tension be 
sHghtly above or below the normal. But the application of 
these symbols to the varying degrees of tension depends very 
much upon the observer. '' T -f 2," for instance, will not 
always convey precisely the same idea to every surgeon. 

.The other symptoms of glaucoma are largely due to the 
increased tension, but in chronic glaucorna there are by no 
means so many symptoms as in acute glaucoma. Let us now 
discuss these two great forms of primary glaucoma separately. 
And first as to chronic, or non-inflammatory, glaucoma 




Fig. ^1.— {Ed. Jaeger.) 

sc. Sclerotic, ch. Choroid, r. Retina, of. Optic nerve, ca. IntervaginAl space. 
V. External sheath of the opiic nerve. E. Excavation of the papilla. M. 
Margin of the excavation. Ic. Lariiina cribrosa. 



(also known as simple glaucoma, as simple chronic glaucoma, 
and as chronic non-congestive glaucoma). 

Symptoms. — The tension is raised. Sometimes the eye will 
be very hard (T -\- 2, or more), and again it may be but 
slightly raised (T + 0- Even in one and the same eye the 
tension usually varies, and maybe at one time too high and at 
another almost or quite normal. 

The external appearance of the eye is usually quite normal, 
and the pupil reacts well to light. The anterior chamber is 
sometimes a little shallow. 



GLAUCOMA. 341 

On examination with the ophthalmoscope the optic papilla 
is found to be cupped. The optic papilla, being the weakest 
part of the ocular wall, is the first place to give way to the 
high tension ; and after a time it becomes depressed or cupped, 
the excavation being often deeper than the outer surface of the 
sclerotic, and the lamina cribrosa being pushed back (Fig. 97). 
This cupping of the papilla is a most important sign of glau- 
coma, and differs essentially in appearance from the physio- 

K 



K. 






V a 

Fig. 98. — {^Ed. Jaeger.) 

a. Arteries, v. Veins. K. Bending of vessels at margin of the papilla. Vp. 

Vessels on the floor of the excavation, z. Glaucomatous ring. 

logic cupping {vide p. loi), inasmuch as it occupies the entire 
area of the papilla, and has steep, not shelving, sides. As 
shown in figure 97, the walls of the excavation are often hol- 
lowed out, and the ophthalmoscopic effect of this is to give to 
the retinal vessels the appearance of being broken off at the 
margin of the papilla (Fig. 98), where they pass round the 
overhanging edge of the excavation, and become hidden by it, 
while on the floor of the excavation they reappear. 



342 



DISEASES OF THE EYE. 



The presence of an excavation may be recognized ophthal- 
moscopically, in the examination by the indirect method, by 
means of lateral motions of the convex lens. It will be then 
seen that, while the whole fundus seems to move along with 
the motion of the lens, the floor of the excavation apparently 
moves in the same direction, but at a slower rate. This paral- 
lax is the more marked the deeper the excavation. The phe- 
nomenon is explained by the accompanying figure (Fig. 99). 
If o be the optic center of the lens being used in the exami- 
nation, and /; and a two points lying one behind the other, the 
inverted images of these points will be situated at b' and a' . 




Fig. 99. 



The line a' b' lies in the visual line of the observer ; and if the 
lens be moved upward a very little, so that the optic center 
comes to o\ the inverted images of b and a will be removed 
to b'^ and rt^. If the observer has not altered his point of view 
it will seem to him that the point b has made a more extensive 
motion than the point a ; or that it has moved more rapidly 
than a, and has glided between a and the observer. Short 
and rapid motions of the lens from side to side, or from above 
downward, will best show the parallax. 

In the upright image the existence of an exca\'ation may 



j 



GLAUCOMA. 343 

be ascertained b}' observing that a lens of a different power is 
required in order to obtain a clear image of the margin of the 
papilla and of its floor. The depth of the excavation may be 
estimated by noting the difference between these two lenses ; 
e. g., if the general fundus of the patient be emmetropic, and 
the emmetropic observer require three D to see the floor of 
the excavation, the depth of the latter is about one mm., and 
in the same proportion up to ten D. 

Besides being cupped, the optic papilla becomes atrophied 
from the pressure, and its consequent paUor serves to aid the 
diagnosis between this and a physiologic excavation. But 
we meet with cases in which the optic disc is cupped and 
pale, and in which the existence of increased tension is doubt- 
ful, and where there is no history of glaucomatous attacks. 
And here, sometimes, the diagnosis between glaucoma and 
primary atroph}' of the optic nerve, with cupping of the disc, 
is one of the most difficult to be met with — indeed, it must 
sometimes be regarded as impossible. The examination of 
the field of vision ma}- not always assist, for in each of these 
diseases it is liable to be contracted."^ Possibly the effect of 
a miotic on the intraocular pressure may aid the diagnosis, 
for it would not materially influence normal tension, while it 
would reduce abnormally high tension. Also the fact that in 
glaucoma the L.M. is affected, and the L.D. is almost normal, 
while in optic atrophy the reverse is apt to be found. 

Around the margin of the glaucomatous excavations, espe- 
cialh- in chronic simple glaucoma, one usually sees the whitish 
appearance termed the glaucomatous ring (Fig. 98), which is 
said to be due to atrophy of the choroid from pressure. 

A pulsation of the arteries on the optic papilla may be 

* BJerruni regards cases of atrophy with excavation as truly glaucomatous, 
because he finds the fields resemble those of undoubted glaucoma in their shape 
and in the tendency which the contraction often has to approach the blind spot. 
{Nordisk Ophthalm. Tidsskrift. , Vol. l.j 



344 DISEASES OF THE EYE. 

often noted, or if not present may be easily produced by very 
slight pressure with the tip of a finger on the eyeball — 
because blood can only be forced into these vessels by a pres- 
sure greater than that opposed to it. In the normal eye there 
is no arterial pulsation, and slight pressure with the tip of 
the finger would not bring it on, for the tension of the 
coats of the vessels is greater than the intraocular tension ; 
and therefore the blood passes on in a continuous stream. 
But in the glaucomatous eye the intraocular tension opposes 
so great an obstacle to the arterial flow, that at the systole 
alone can it make its way through. 

Arterial pulsation also occurs, although rarely, in exoph- 
thalmic goiter (see Chap, xix) ; and it occurs where the press- 
ure in the arteries themselves is low (weak heart's action, 
aortic regurgitation, etc.), although that in the vitreous 
chamber be normal. 

The acuteness of vision is diminished, and increasing dim- 
ness of sight is the only symptom of which the patient 
complains in chronic simple glaucoma. Besides this, the field 
of vision becomes contracted in consequence of interruption 
to conduction in the retinal nerve-fibers from pressure on them 
at the margin of the depressed optic papilla. This contraction 
of the field must always be examined for by the recognized 
methods. It commences at the nasal side as a rule, while at 
the same time central vision is lowered, and later on the 
temporal portion of the field becomes contracted, and gradu- 
ally absolute blindness is brought about. 

The light-sense in glaucoma is defective, both as regards 
L.M. and L.D. ; or else only as regards L.M., which is much 
greater than normal. 

The progress of the disease is extremely slow, extending 
often over several years, and ends in total blindness if un- 
treated. It usually attacks both eyes, but generally one 
of them long before its fellow. Sometimes chronic simple 



GLAUCOMA. 345 

Sflaucoma, after a time, takes on the acute or the subacute 
form. 

Acute, or Inflammatory, Glaucoma (also called Acute 
Congestive Glaucoma). — In this form the increase of tension 
is always very marked. In addition to this there are the fol- 
lowing symptoms : 

Diminished depth of the anterior chamber, from pushing 
forward of the lens and iris. 

Diminution of the refracting power of the eye, by reason of 
the nearer approach of the latter to a globular shape. 

Diminution of the amplitude of accommodation, and anes- 
thesia of the cornea, owing to pressure on the ciliary nerves 
as they pass along the inner surface of the sclerotic. 

Opacity of the cornea, giving its surface a peculiar steamy 
or breathed-on appearance, due to edema of the corneal tissue 
and epithelium, b}' infiltration into them of the intraocular 
fluids from high tension. A similar opacity of the cornea is 
sometimes seen in iritis and iridochoroiditis, and in interstitial 
keratitis. 

Indistinctness of the pattern of the iris, similar!}' due to 
edema. 

Opacity of the aqueous and vitreous humors. 

Dilatation and immobility of the pupil, the result, according 
to some, of paralysis of the ciliary nerves, but, according to 
others, of anemia of the iris from pressure on its vessels. The 
pupil is oval, with its long axis vertical. 

The episcleral veins are large and tortuous, owing to the 
pressure on the vasae vorticosae, preventing the discharge 
by those channels of the choroid venous blood, which must 
then pass off by the anterior ciliar}' veins. 

Subjective appearances of light and color, and colored halos 
or rainbows around lamps and candles, are complained of. 
Similar appearances are sometimes experienced by persons 
suffering from chronic conjunctivitis. 
29 



346 DISEASES OF THE EYE. 

Pain is a very marked symptom of acute glaucoma, both in 
the eye, and radiating over the corresponding side of the head. 
This pain is often very violent. 

Vision is greatly affected, and the field of vision will be 
found contracted in cases of some standing. 

The optic papilla, when the media are sufficiently clear to 
admit of its being examined, is seen to be cupped if the disease 
have continued sufficiently long to bring about this change. 

In acute glaucoma we recognize CGYidAW pniiionitoiy symptoms , 
viz. : sudden diminution of the amplitude of accommodation, 
evidenced by the rapid onset or increase of presbyopia, and the 
consequent necessity for higher -f glasses for near work ; and 
the occasional appearance of colored halos around the flames 
of lamps or candles, with attacks of fogginess of the general 
vision. The duration of one of these foggy attacks may be 
from a few minutes to several hours. Such attacks are apt to 
occur after a sleepless night, or after a meal, and are some- 
times accompanied by periorbital pains. Slight opacity of the 
aqueous humor, and sluggishness of the pupil, with some dila- 
tation, are present during an attack ; but afterward the eye 
returns to its normal condition, and remains so for weeks or 
months, until another similar attack comes on. Such a pre- 
monitory stage may last a year or longer, but cases also occur 
in which there is no premonitory stage. 

The onset of the tnie giaiicoviatoiis attack is usually at night. 
It is accompanied by violent pain, radiating through the head 
from the eye ; by pericorneal injection, chemosis, and lacrima- 
tion. The aqueous humor is cloudy, the anterior chamber 
shallow, the iris discolored, and the pupil dilated to medium 
size and of oval shape, the cornea steamy and anesthetic. The 
patient frequently complains of subjective sensations of light, 
and vision is very defective, or maybe quite wanting. V^omit- 
ing very frequently accompanies acute glaucoma, and has often 
led to errors of diagnosis, the patient's ailment having been 



GLAUCOMA. 347 

taken to be a gastric disease, while the ocular symptoms were 
regarded as accidental coincidences, such as a cold in the eye, 
neuralgia, etc. 

An attack like that just described may, to a great extent, 
pass away in the course of a few days, but a complete remis- 
sion of all the symptoms does not come about. Some defect 
of central vision is left, or, it may be, some slight peripheral 
defect in the field of vision ; the tension does not become quite 
normal again, and the pupillary motions remain slightly slug- 
gish. Another acute attack of glaucoma comes on in the 
course of some weeks or months, and it, too, may pass away, 
leaving the eye in a still worse condition than it found it. The 
attacks gradually become more frequent ; and if in the inter- 
vals the eye be examined, the cornea and vitreous humor will 
be found more or less opaque, the optic papilla cupped, and 
an arterial pulsation may be discovered. Finally, there is no 
remission from the attack, the violent glaucomatous symptoms 
become permanent, and all vision is forever destroyed. 

Even when vision has been destroyed the high tension con- 
tinues, and gradually produces disorganization of the tissues 
of the eyeball (glaucomatous degeneration). The iris becomes 
atrophied, the lens becomes opaque, and the cornea frequently 
ulcerates, while hemorrhages are apt to occur in the antei'ior 
chamber. In time the excessive intraocular tension causes 
staphylomatous bulging of the sclerotic in the ciliary region, 
or further back ; and, finally, such eyes may become the sub- 
jects of acute purulent choroiditis, and end in phthisis bulbi. 

Acute glaucoma almost always comes on in both eyes, 
either at the same time, or with an interval, it may be of weeks 
or of months. 

The reason why there is so marked a difference between the 
symptoms and course of chronic and of acute glaucoma is 
probably that in the former the increase of tension is very 
gradual, and therefore the eye gradually becomes accustomed 



348 DISEASES OF THE EYE. 

to it ; while in acute glaucoma the increase is rapid or sudden, 
and the circulation of the eye has not time to accommodate 
itself to the new state of things. 

Glaucoma fiilniinans is the name given by von Graefe to a 
form of the disease which is more acute than the ordinary 
acute glaucoma just described. It has no premonitory stage, 
and, coming on with all the symptoms of acute glaucoma 
greatly exaggerated, does not remit, and causes complete per- 
manent destruction of vision in the course of a few hours. It 
is a rare form. 

Subacute Glaucoma. — This form differs from acute glau- 
coma in that its premonitory stage merges gradually into the 
actual disease without the occurrence of an acute attack. The 
eye gradually becomes hard, the pupil dilated, the anterior 
chamber shallow, the aqueous humor opaque ; while the cor- 
nea is " steamy" and anesthetic, and the episcleral veins are 
distended. Ophthalmoscopically, the cupped disc and pulsat- 
ing arteries may be seen when the opacities of the media per- 
mit. Vision sinks, and the field is contracted toward its nasal 
side. The progress of the disease is very slow ; and in its 
course attacks of ciliary neuralgia, with greater increase of the 
tension, greater opacity of the aqueous humor, increase of the 
corneal opacity and anesthesia, and further dimness of vision, 
are experienced. These attacks pass off again in the course 
of a few days or hours, leaving the eye harder and blinder than 
before. The subacute glaucoma sometimes takes on the acute 
form. It is liable to bring about the same glaucomatous de- 
generation of the eye as does the latter. 

Eiiology of Glaticoma. — Glaucoma is a disease of advanced 
life, occurring most usually after fifty years of age, and rarely 
under the thirtieth year. It is not peculiar, or more common 
to any one constitution or temperament. Anxiety, sorrow, 
and influences in general which depress the spirits have often 
been noticed to precede the onset of acute glaucoma. 



GLAUCOMA. 349 

As regards the patJiology of glaucoma^ the theory which of 
late years has obtained most acceptation owes its origin to 




Fig. ioo. — Diagrammatic Representation of Normal Condition. 

/. Angle of anterior chamber and ligamentum pectinatum. s. Canal of Schlemm. 

/. Venous plexus of Leber. 

Max Knies * and Adolf Weber, f and is known as the retention 
theory. These observers ascertained that in glaucomatous 




Fig. ioi. — Diagrammatic Representation of Glaucomatous Condition. 
I' . Obliterated angle of anterior chamber. 

eyes the periphery of the iris lies in contact with the periphery 
of the cornea (Figs. loo and loi) in the region of the canal 

*Von Graefe^ s Ai-chiv, xxii, pt. iii, p. 163, and xxiii, pt. ii, p. 62. 
'\ Ibid., xxiii, pt. i, p. I. 



-350 



DISEASES OF THE EYE. 



of Schlemm, venous plexus, and ligamentum pectinatum. But 
this region and these tissues having previously been proved by 
Leber * to be the ways of exit of the effete intraocular fluids, 
which flow to that point from the posterior part of the aqueous 
chamber through the pupil, Weber and Knies concluded that 
the blocking of these passages from the close application of 
the iris caused glaucoma by preventing the effete fluids from 
escaping ; and thus the disease was rendered one of retention 
rather than of hypersecretion, as it had previously been con- 
sidered to be. Weber believes that swelling of the ciliary 
processes, from one cause or another, pushes the periphery of 
the iris forward, and gives the starting-point for glaucoma. 

Brailey f to a certain extent adopts this view of Weber, but 
regards J a chronic inflammation of the ciliary processes and 
periphery of the iris, with distension of the blood-vessels of 
these parts, to be the chief factor in the earliest history of the 
disease. 

Max Knies § also now regards glaucoma as an irido- 
cyclitis, which, owing to varying intensity, produces the 
different forms of the disease. 

Priestley Smith || adopts the retention theory, and holds 
that the main predisposing cause of primary glaucoma is an 
insufficient space between the margin of the lens and the 
structures which surround it ; and he attributes the greater 
liability of elderly people to the progressive increase in the 



*Vo7t Graefe'' s Airhiv, xix, pt. ii, pp. 87-185. 

t Ophih. Hosp. Rep., x, p. 282. 

\Ibid., ix, p. 199, and x, pp. 14, 89, 93. 

\Archiv f. Ophthalin.,Y^x\7v^^ and Schweigger. German Ed., xxxviii, 1894, 
P- 193- 

II "On Glaucoma," 1879, Ophih. Hosp. Rep., x ; Trans. Inteniat. Med. Con- 
gress, 1881 ; Ophthalmic Reviezv, July, 1 88 7. " Pathology and Treatment of 
Glaucoma," London, 1891. 



GLAUCOMA. 35-1 

size of the lens, which he has proved * to occur as hfe 
advances. In eyes in which the circumlental space is in- 
sufficient, by reason either of the original structure of the 
eye — and small eyeballs, as Priestley Smith has shown, are 
specially liable to primary glaucoma, a fact often demonstrated 
by the small size of the cornea in the eyes attacked — or of 
the enlargement of the lens, any condition which tends to 
overfill the veins of the head and uveal tract may initiate 
an attack of acute glaucoma, as follows : An increase in the 
amount of blood in the uveal tract must be compensated by 
the expulsion of some other fluid from the eye^ — the aqueous 
humor filters out more rapidly at the angle of the anterior 
chamber. As the contents of the chamber diminish, the lens 
and iris move forward toward the cornea. Now, in the normal 
eye, and especially in the youthful eye, this compensation is 
effected without danger to the angle of the anterior chamber, 
because the lens is comparatively small, the circumlental space 
large, and the anterior chamber deep. But when the lens 
and ciliary processes are already in close relation to each 
other, and the anterior chamber already shallow, then any 
increased fulness of the uveal tract involves danger to the 
angle of the chamber. The turgid ciliary processes find 
insufficient space for their expansion ; they are carried forward 
together with the lens, and, pressing upon the base of the iris, 
lock up the angle of the anterior chamber. Thereupon, the 
further escape of fluid being impossible, high tension of the 
eyeball is established. According to this explanation, then, 
the high tension is due to impeded escape of the intraocular 
fluid, not to hypersecretion, and depends primarily rather 
upon an increase in the amount of blood in the eye, than on 
an excess of the intraocular fluid. Mr. Priestley Smith con- 
siders that in chronic simple glaucoma the predisposing causes 

* Trans. Ophth. Soc. U. K., iii, p. 79. 



352 DISEASES OF THE EYE. 

are the same as in acute glaucoma, but that in the former, the 
vascular disturbance being gradual and slight, the vessels 
adapt themselves to the slowly-increasing pressure, and the 
angle of the anterior chamber is more or less compressed, but 
not tightly closed. 

Von Graefe * believed that a serous choroiditis lay at the 
root of the disease, which he thought was caused by exudation 
of serous fluid into the vitreous humor; while Bonders, f von 
Hippel and Grunhagen,J and others held that irritation of the 
fifth pair of nerves, governing the secretion of the intraocular 
fluids, gave rise to hypersecretion of those fluids. 

Others, again, held that changes in the sclerotic, rendering 
it rigid and leading to some shrinking of it, caused the 
increased intraocular tension. 

Laqueur § believes that some such sclerotic changes pro- 
duce obstruction of the posterior ways of exit of the intra- 
ocular lymphatics — namely, those which pass out with the four 
vasse vorticosae, and that glaucoma depends largely upon this 
obstruction. 

Treatment. — The performance of an iridectomy is the means 
discovered by von Graefe, || in the year 1857, for the cure of 
glaucoma, a disease which had hitherto been incurable. This 
measure held an undisputed position as the sovereign remedy 
for the disease until a few years ago, and even yet has not 
suffered much from the competition of the operation of 
sclerotomy. 

To insure the success of an iridectomy for glaucoma, so 
far as possible, it is necessary (i) that the incision should be 
peripheral — /. r., as far back in the corneosclerotic margin as 

* Archiv f. OphthaL, xv, pt. iii, p. lo8, and elsewhere. 

f Ibid., ix, pt. ii, p. 215. 

\ Ibid., xiv, pt. iii ; xv, pt. i ; and xvi, pt. i. 

\ Von Graefis Archiv, xxvi, pt. ii. 

II Archiv f. OphthaL, iii, pt. ii, p. 456. 



GLAUCOMA. 353 

is compatible with the introduction of the knife into the 
anterior chamber, and with the avoidance of injury to the 
cihary body ; (2) that the portion of iris removed should be 
wide — /. e., involving about one-fifth of the entire circum- 
ference of the iris (see p. 296 and Fig. 93). 

It is, moreover, important to withdraw the knife very slowly 
from the anterior chamber, when the corneoscleral section is 
complete, in order that the aqueous humor may flow off gradu- 
ally, and the occurrence of an intraocular hemorrhage from 
the sudden reduction of tension avoided. The portion of iris 
should be most carefully abscised, so that no tag of it may 
remain in the wound, and become caught in the cicatrix in 
the course of healing. Such an occurrence is apt to produce 
a cystoid cicatrix, which may at a later period become the 
starting-point of irritation, and even of serious inflammation. 
Some operators prefer von Graefe's cataract knife for the per- 
formance of the operation, but the ordinary lance-shaped iri- 
dectomy knife is the instrument usually employed. For the 
purpose of reducing the intraocular tension it matters nothing 
what region of the iris be abscised ; but, as a rule, the upper 
quadrant is to be preferred, for there the resulting coloboma, 
being covered to a great extent by the upper lid, will give rise 
to less diffusion of light than in any other position. 

Immediately after the operation, palpation of the eyeball 
should show a marked diminution of tension. When this is 
not so, the prognosis is unfavorable. Should an increase of 
tension occur on the day after the operation it is of no conse- 
quence, as it passes off again in the course of the next few 
succeeding days. Until then the anterior chamber will not 
be restored, and we see cases where the anterior chamber does 
not appear for a week or more. The bandage should be worn 
until the anterior chamber is completely restored. I do not 
care for the use of eserin after a glaucoma operation, as I 
think it sometimes produces iritis. Von Graefe recommended 
30 



354 DISEASES OF THE EYE. 

that if immediately after the iridectomy the intraocular tension 
continues high no bandage should be applied, as he believed 
it to do harm, but advised that the eyelids should simply be 
kept closed with a strip of court-plaster. The pain for some 
time after the operation is considerable, but may be relieved 
by a hypodermic injection of morphin in the corresponding 
temple. 

Very occasionally, immediately after iridectomy, although 
the operation may have been faultlessly performed, the case 
takes what we call a malignant course. In these cases the 
lens seems to be violently pushed forward, blocking the wound, 
obliterating the angle of the anterior chamber, and preventing 
any fluid from escaping from the eye, so that very soon it is 
as hard, or harder, than before. This complication seems to 
be caused by the retention of fluid behind the lens, and is 
more likely to occur in cases of chronic simple glaucoma than 
in the acute forms of the disease. 

Unless the method recommended by Adolf Weber for these 
cases be employed with success, all such eyes are inevitably 
lost, are apt to become very painful, and must often be excised. 
Weber * introduces a broad needle, or a Graefe's knife, through 
the sclerotic, eight or ten mm. behind the outer margin of the 
cornea, and gives the blade a quarter turn on its axis, so as 
to make the wound to gape. At the same time he applies a 
gradually-increasing pressure, by means of the upper lid, on 
the center of the cornea. This causes fluid to escape through 
the scleral wound by the side of the knife, and it also causes 
the lens to go back into its place, with restoration of the an- 
terior chamber. The pressure on the cornea may be main- 
tained with advantage for a minute or somewhat longer. Mr. 
Priestley Smith speaks highly of this procedure, but, I am 
happy to say, I have not had the necessity to resort to it. 



Fon Graefi s Archiv, xxiii, i, p. 86. 



GLAUCOMA. 355 

As a rule, the more acute the form of glaucoma, and the 
earlier in the disease the iridectomy be performed, the more 
favorable is the prognosis in respect of the result which may 
be expected. The saving of normal vision can only be looked 
for in those cases, chiefly of the acute form, where it has as 
yet fallen but little, or not at all, below the normal, and where 
the contraction of the field has barely commenced. When 
the disease has interfered seriously with vision (of course I do 
not refer here to the enormous loss of sight immediately 
attendant upon an attack of acute glaucoma, for this is usually 
restored) we should not expect more than the retention of 
the status in quo. But our prognosis, even in this respect, 
should be most guarded, especially in chronic simple glaucoma, 
when the contraction of the field is found to have approached 
close to the fixation point, although central vision may be 
fairly good. Because in such cases, while the iridectomy may 
prove successful so far as reduction of tension is concerned, 
yet the contraction of the field — /. e., the progress of the 
atrophy of the optic nerve — is often not arrested, and shortly 
afterward may be found to engulf the center of vision. It 
may, indeed, be stated that while the result obtained from 
iridectomy in acute and subacute glaucoma, on the bases 
above laid down, can be regarded as amongst the most satis- 
factory in the whole range of ophthalmology, in chronic simple 
glaucoma iridectomy does not act with the same degree of 
success, and the prognosis should therefore be guarded in 
these cases. 

In cases of acute or subacute glaucoma it has frequently 
been observed that shortly, even within a few hours, after the 
performance of the iridectomy, the other eye, previously 
healthy, or, at most, affected with but slight premonitor)- 
symptoms, is attacked with glaucoma. It is probable that this 
is due to dilatation of the pupil, with crowding of the iris into 
the angle of the anterior chamber, in consequence of confine- 



356 DISEASES OF THE EYE. 

ment in the dark room. Hence some operators put eserin 
into the sound eye as a precaution. 

It may here again {vide p. 287) be stated that the use of 
atropin, or of any other mydriatic,* in an eye with a tendency 
to glaucoma is liable to bring on an acute attack of the disease, 
and must be carefully avoided in such cases. 

If the tension be not relieved by the iridectomy, a supple- 
mental iridectomy may be performed after a time, and von 
Graefe recommended that it should be placed at the opposite 
side of the pupil from the first coloboma. 

The mode of action of the operation is not clearly known. 
Von Graefe at one time believed it to act by diminution of the 
secreting surface of the intraocular fluids. DeWeckerf and 
Stellwag X — even previously to the formulation by Knies and 
Weber of the retention theory of glaucoma already referred 
to — held that the cure depended, not on the removal of the 
portion of iris, but on the incision in the corneosclerotic 
margin, or, rather, on the nature of the cicatrix resulting from 
that incision. They maintained that this cicatrix was formed of 
tissue, which admitted of a certain amount of filtration through 
it of the intraocular fluids, and that in this way the intraocular 
tension was kept down to the normal standard. This theory 
has gained support from that of Knies and Weber. 

Priestley Smith has satisfied himself that in a large number 
of successful iridectomies the success is due to a permanent 
corneoscleral fistula — not merely a filtration cicatrix — having 
been formed. The same view is held by Treacher Collins, § 
who finds that this permanent gap is maintained by a prolapse 



* See Opiithal. Reviezv, 1893, p. 69, where Mr. Story records a case of glau- 
coma produced by cocain in a child thirteen years of age. 
f Bericht der Ophthal. Gesellsch. zu Heidelberg, 1 869. 
X " Der Intraoculare Druck," etc., Vienna, 1868. 
^ Roy. Land. Ophthal. Hosp. Rep., December, 1891. 



GLAUCOMA. 357 

of a fold of iris into the wound. The latter author, indeed, 
entirely and definitely discards the filtration cicatrix theory, for 
which he considers there is no evidence. In those cases where 
a fistula, as described, is not formed by the operation, Treacher 
Collins considers that the obstruction becomes freed, either 
b}' the iris being torn away at its thinnest part — that is, 
its extreme root, thus leaving a large portion of the filtra- 
tion angle open for drainage — or by the escape of the aqueous 
and the drag on the iris, incident on the iridectomy, being 
sufficient to dislodge the peripher}' of an iris, which has only 
recently come into apposition with the cornea. 

De Wecker, Stellwag,* and Quaglino t sought to produce 
the corneoscleral filtration cicatrix without the removal of a 
portion of iris. The peripheral position of the wound, how- 
ever, rendered the proceeding difficult 
or impossible, owing to the tendency to 

prolapse of the iris which necessarily 

o — 
existed. The introduction of eserin into 

ophthalmic practice at last enabled de 

Wecker to place the operation on a -p^^ ^^^ 

surer footing, as the miosis produced 

by instillation of a solution of this drug into the eye insured 

the operator, to a great extent, against the danger of prolapse 

of the iris ; and hence : 

Sclerotomy , as the operation is called, has come to be culti- 
vated as a method for the relief of glaucoma, and has proved 
useful as such. It has hitherto been employed more in chronic 
simple glaucoma — a form in which, as I have stated, iridectomy 
is less satisfactory than in acute or subacute glaucoma. Care 
must be taken that the pupil is contracted to pinhole size, or 



^ Bericht dej- Ophthal. Geselhch. zti Heidelberg, 1 87 1; " Chirurgie Oculaire,' 
p. 212. Paris, 1879. 

^ Ajinali di Ophthalmologia, i, pt. ii, p. 200, 187 1. 




358 DISEASES OF THE EYE. 

nearly so, when the operation is about to be performed, as 
otherwise the danger of prolapse of the iris is very great. In 
those cases where eserin will not produce a sufficient miosis, 
sclerotomy should certainly not be performed. 

Priestley Smith and Treacher Collins explain the cure b)' 
sclerotomy in the same way as they do that by iridectomy. 

The instrument used for performing the operation is von 
Graefe's cataract knife. A speculum having been applied, and 
the eyeball fixed, the point of the knife is entered into the 
anterior chamber, through the corneosclerotic margin, at a 
point of its circumference corresponding to that selected for 
the puncture in cataract extraction, but one mm. removed from 
the corneal margin, as represented at a in figure 102. The 
counterpuncture is made at a point {U) corresponding to this, 
at the other side of the anterior chamber. With a sawing 
motion of the knife the section is enlarged upward, until only 
a bridge of tissue, about three mm. broad, remains at c, and 
this is left undivided, the better to guard against prolapse 
of the iris. The knife is now slowly withdrawn from the 
eye, care having been first taken that the aqueous humor is 
thoroughly evacuated, which can be effected by tilting the edge 
of the knife slightly forward, so as to make the lips of the 
wound gape somewhat. If the pupil be quite round at the 
conclusion of the operation, the bandage may be applied, a drop 
of solution of eserin having been first instilled ; but if the 
pupil be oval, or of other irregular shape, a tendency to pro- 
lapse of the iris is indicated, and the hard rubber or silver 
spatula should be introduced into the anterior chamber, to re- 
store the pupil to its normal shape by gentle pushing of the 
iris. If there be an actual prolapse of the iris, an attempt may 
be made to repose it with the spatula ; but should this not 
prove satisfactory the prolapse is to be abscised with scissors, 
thus turning the sclerotomy into an iridectomy. 

The Treatment of Glaucoma by Miotics. — Eserin and pilo- 



GLAUCOMA. 359 

carpin as eye-drops in two per cent, solutions often have the 
power of reducing glaucomatous tension. This power depends 
on the contraction of the pupil and consequent drawing 
away of the base of the iris from the angle of the anterior 
chamber; and if the miotic does not contract the pupil 
greatly, it will not reduce the tension. Cases of acute glau- 
coma, brought on by the injudicious use of atropin, may 
frequently be completely and permanently relieved by a 
miotic instilled a few times. In acute glaucoma of the 
ordinary type, the use of a miotic in the premonitoiy stage 
will often postpone the true glaucomatous attack, and even 
sometimes relieve the latter for the time ; but the miotic treat- 
ment cannot produce a radical cure, and it should only be used 
to preserve the health of the eye until the operation is per- 
formed. In chronic simple glaucoma, also, miotics bring 
down the tension if they contract the pupil, and may be used 
in those cases where the patient will not submit to an opera- 
tion, or where an operation in the fellow eye has not resulted 
satisfactorily, or where an operation is contraindicated by a 
very contracted field. The anti-glaucomatous action of the 
miotic only lasts so long as the pupil is contracted ; and if the 
pupil cannot be contracted, no such action is to be looked for. 

In the miotic treatment of glaucoma, Priestley Smith recom- 
mends the combination of cocain with the miotic in such 
proportions (say, about -^ per cent, of cocain to one per cent, 
of the miotic) that the miotic will have the mastery over the 
pupil. For although, like every dilator of the pupil, when 
used alone, cocain may promote high tension, yet it has the 
powers, invaluable in glaucoma, of contracting the ciliary 
blood-vessels and of diminishing the sensibility of the ciliary 
nerves ; and, when used in the foregoing manner, the advantage 
of each drug may be obtained without any of the disadvantages 
of either. 

It may here be once more stated that, while miotics 



36o DISEASES OF THE EYE. 

possess the power of reducing glaucomatous tension, atropin, 
and all mydriatics, bring on glaucoma where there is already 
a tendency to it. In all old people, therefore, before atropin 
is used, it is well to ascertain that the tension is not too high. 
Treatment of Painful Blind Glauconiatons Eyes. — Eyes blind 
of acute glaucoma may, as I have stated, continue to be pain- 
ful, and may in this way render the patient's life very miser- 
able. Iridectomy is very commonly performed to relieve the 
pain, although all hope of restoration of sight is lost ; but the 
operation sometimes fails in its object. Neurectomy (Chap, x, 
p. 320) seems to offer a more certain result, and, of course, 
enucleation or evisceration would have the same effect. 

Secondary Glaucoma. 

In addition to the different forms of primary glaucoma above 
described, we find, as already stated, that high tension occurs 
as a sequel of diseased conditions previously existing in the 
eye. There are several diseased states which are liable to 
become complicated with glaucomatous tension ; but it should 
be clearly understood that in almost every instance the im- 
mediate cause of the high tension is the same as in primary 
glaucoma — namely, a closure of the angle of the anterior 
chamber. 

The following are the chief conditions which are liable to 
lead to secondary glaucoma : 

a. Complete posterior, or ring synechia (wV/^' p. 284). The 
iris, being pushed forward by the aqueous humor pent up 
behind it in the posterior part of the aqueous chamber, is 
pressed tightly against the cornea, and obliterates the angle of 
the anterior chamber and the ways of exit. An iridectomy 
relieves the high tension here. 

b. Perforating wounds or ulcers of the cornea, followed by 
incarceration of the iris in the resulting cicatrix. The iris, being 
drawn tautly toward the cornea, a large portion, or the whole, 



GLAUCOMA. 361 

of the filtration angle may be closed by it. An iridectomy is 
indicated. Lang divides anterior synechiae by means of his 
twin knives. 

c. Dislocation of the crystalline lens into the anterior cham- 
ber. Here the normal flow of the intraocular fluids through 
the pupil {vide p. 410), on its way to the filtration angle, is 
arrested by reason of the presence of the lens in the anterior 
chamber. The onward current then presses the iris against 
the posterior surface of the lens, and the root of the iris, which 
is unsupported by the lens, against the periphery of the cornea, 
and in this way the angle of the anterior chamber is closed. 
In these cases the lens must be removed from the eye. 

d. Lateral (traumatic) displacement of the crystalline lens. 
The lens, being pushed in between the ciliary processes and 
the vitreous humor, drives the root of the iris forward against 
the cornea at that place, while in other parts of the circum- 
ference the displaced vitreous acts in the same way. In these 
cases, too, the lens must be removed. 

c. Injury of the crystalline lens {inde Chap. xiii). The swell- 
ing lens pushes the iris forward against the angle of the anterior 
chamber. Evacuation of the lens should be performed. 

f. After cataract extraction. For explanation of this see 
chapter xiii. 

g. Intraocular tumors (z^/rt'^ p. 310). The growth of the 
tumor gives rise to a transudation of serum from the choroid 
which detaches the retina, and after a time pushes the lens, 
the ciliary processes, and the iris forward, and thus closes the 
filtration angle. 

h. Serous-cyclitis, or iritis. Here the filtration angle is not 
closed. Mr. Priestley Smith thinks that the increased tension 
is due to diminished filtration power of the eye, and perhaps 
by tissue changes around the filtration angle. 

Another, and very peculiar, form of secondary glaucoma is : 
Hemorrhagic Glaucoma. — Retinal hemorrhages of the 



362 DISEASES OF THE EYE. 

ordinary type are sometimes followed, a few weeks later, by 
increased intraocular tension, which generally assumes the 
symptoms of acute or subacute glaucoma, and, more rarely, 
those of chronic simple glaucoma. A satisfactory explanatioji 
for these cases has not, so far as I am aware, been offered. 
When such a glaucoma has become pronounced, it is not 
usually possible to distinguish it from a primary form of the 
disease. 

Treatment. — Iridectomy in hemorrhagic glaucoma is more 
likely to do harm than good, the operation being almost 
invariably followed by fresh intraocular hemorrhages and by 
a further increase of tension. Sclerotomy is said by some to 
act with fairly good results in hemorrhagic glaucoma. The 
miotic treatment is powerless. 

Congenital Hydrophthalmia, 
also known as buphthalmia and cornea globosa, is a disease 
of early childhood, of which the incipient stages are believed 
to be intrauterine. The cornea becomes enormously enlarged 
in diameter, the anterior chamber deep, the iris trembling, and 
the sclerotic thinned. Increase of tension, often attended by 
severe pain, and cupping of the optic papilla, are usually 
present. The disease is regarded as a secondary glaucoma, 
although it is by no means certain that it should not rather be 
considered as a form of primary glaucoma, occurring in young 
children. 

Treatment. — Iridectomy and sclerotomy are alike followed 
by disastrous results in this disease. The miotic treatment 
is the only one applicable, and in a few cases it arrests the 
disease. 



CHAPTER XIII. 

DISEASES OF THE CRYSTALLINE LENS. 

Cataract, by which is meant an opacity of the lens, may be 
said to be the only disease of this part of the eye. Cataract 
maybe complete — i. e., occupying, in its final stage, the whole, 
or nearly the whole, of the lens ; or partial — /. e., occupying 
only part of the lens, and with Uttle or no tendency to extend 
to other parts of it. 

Complete Cataracts. 

Of these, the most common is senile cataract. It occurs 
in persons of over fifty years of age, rarely in those under 
forty-five years of age. 

Progress, Pathogenesis, and Etiology of Senile Cataract. — In 
commencing or incipient senile cataract the opacity is found in 
the cortical layers of the lens, especially at its equator, and in 
the latter position can often only be detected with transmitted 
light from the ophthalmoscope mirror, or with oblique light, 
even when the pupil is dilated with atropin. This opacity 
takes the form of lines, or of triangular sectors, of which the 
bases are toward the equator of the lens, while the apices are 
toward its center. These lines and sectors look black with 
transmitted light, but gray with oblique light, and between 
them clear lens substance is present. Or incipient cataract 
may first appear as a diffuse opacity in the layers surrounding 
the nucleus of the lens. Or the opacity may commence both 
near the equator and around the nucleus at about the same time. 
Or, again, the opacity may, in the beginning, be disseminated 

363 



364 DISEASES OF THE EYE. 

through the cortex, in the form of flocculi, dots, and Hnes. 
In some cataracts, in a very incipient stage, there are no abso- 
lute opacities; but with weak transmitted light — /. ^., from a 
plane mirror — numbers of fine dark lines will be seen in the 
lens, which vanish and reappear according as the incidence of 
the light is altered ; while a little later on true opacities make 
their appearance. Gradually the cataract extends to other 
parts of the lens, until the whole cortical portion is opaque. 

In senile cataract the very nucleus itself does not become 
cataractous, although it is usually sclerosed (harder and drier). 
Sclerosis of the nucleus of the lens is a physiologic condition 
of advanced life, and will be found in many an eye where there 
is no cataract. It gives to the non-cataractous lens, as seen 
with a dilated pupil or with focal illumination, a peculiar 
smoky appearance, which is often mistaken by inexperienced 
persons for cataract ; but examination with transmitted light 
will show that there is no opacity. When a senile cataract 
has become complete, the sclerosed nucleus imparts to its cen- 
ter a brownish or yellowish hue, while the other parts of the 
lens are of a grayish white. As a rule, the most peripheral 
layers of the cortex are the last to become opaque. Ac- 
cordingly as the lens becomes opaque, it often swells some- 
what, and the anterior chamber consequently becomes a little 
shallower. 

Until the whole cortex is opaque, a clear interval will be 
present between the iris and the cataractous part, and on ex- 
amination with the oblique light a shadow of the iris will be 
thrown on the cataractous part at the side from which the 
light comes ; and the cataract, in this way, is proved to be im- 
mature in the strict sense. If the whole cortical substance be 
opaque, the thickness of the capsule alone will intervene be- 
tween the pupillary margin and the opacity. In addition to 
this examination with the focal light, the pupil should be dilated 
and the lens examined by transmitted light from the ophthal- 



THE CRYSTALLINE LENS. 365 

moscope mirror, when a completely opaque cataract should 
permit of no red reflection being obtained in any direction 
from the fundus oculi. 

As soon as the whole of the cortical substance has become 
opaque, the swelling of the lens begins to subside, and the 
anterior chamber finally regains its normal depth. If there 
be no glittering sectors in the cortex, the cataract is now 
''mature," or ''ripe" for operation — i.e., if an extraction 
operation be now undertaken it is possible to deliver the lens 
in its entirety ; whereas, prior to this stage, some cortical sub- 
stance would have been liable to adhere to the capsule, and 
be left behind. 

But a cataract is immature, despite the absence of shadow 
from the iris, of the illuminable pupil, and even though the 
anterior chamber be of normal depth, if the cortex present 
well-marked, glittering sectors. The glitter of the different 
sectors varies with the angle of illumination, so that the sur- 
face appears faceted. In such a lens there are thin transpar- 
ent flakes, as well as opaque flakes, close beneath the capsule ; 
and if extraction be undertaken, the former are veiy apt to 
remain within the eye in spite of every effort to remove them. 
A few months later the sectors lose their sharp contour, break 
down, and finally disappear. We can then depend upon the 
exit of the whole cataract. 

Yet in persons over sixty years of age, in whom the 
nucleus is usually large, many a cataract can be completely 
removed which does not come up to the strict standard of 
maturity just laid down ; and at that time of life I would not 
hesitate to operate, without waiting for absolute maturity, if 
the patient were materially incommoded for want of sight. 

The foregoing is the most common course of events in the 
progress of a senile cataract ; but there is a rather rare form 
of it, in which total opacity of the cortical layers never does 
come about. In this form the lens is occupied by radiating 



366 DISEASES OF THE EYE. 

linear opacities up to the very capsule ; but between these 
opaque lines there are clear intervals, which may even admit 
of the fundus oculi being examined, although dimly, and 
which allow of a certain amount of sight. 

After the stage of maturity a cataract gradually goes on to 
be hypermature. Here one of two changes takes place : 
either the cortical substance breaks dow^n, and becomes fluid, 
the nucleus retaining its consistency, and gravitating to the 
lowest part of the capsule (Morgagnian cataract) ; or, more 
commonly, the cortical substance dries up, as it were, and 
finally comes to form, with the nucleus, a hard flat disc. 
Accompanying these changes in the lens substance are 
changes in the epithelium lining the inner surface of the an- 
terior capsule, which result in a thickening of the capsule. 
In a Morgagnian cataract the fluid cortex finally undergoes 
absorption, and the anterior and posterior capsules come in 
contact (cataracta membranacea). In some cases the capsule 
remains more or less transparent, and the sight may greatly 
improve. About 20 cases are on record of spontaneous cure 
of cataract, due to intracapsular absorption.* 

The investigations of Priestley Smith f have shown that 
a diminished rate of growth of the lens precedes the formation 
of cataract ; and it is held that the cataractous process in the 
senile lens is the result, in the first instance, of a rapid sclero- 
sis and shrinking of the nucleus. If the process of sclerosis 
and shrinking be very gradual, cataract does not appear, be- 
cause the cortical layers of the lens have time to accommo- 
date themselves to the altered state of things ; but if the 
shrinkage be rapid, the cortical layers cannot so rapidly accom- 
modate themselves, and then the fibrillae of these layers be- 
come separated somewhat from each other, and fluid collects 

* Mitralsky, Centralbl. f. prakt. Augenheilkunde, October, 1 892. 
t Trans. Ophthal. Soc, 1883, p. 79. 



THE CRYSTALLINE LENS. 367 

in the interspaces. This fluid it is which causes the disinte- 
gration of the lens substance, gradually leading to opacity of 
the whole lens. As the opacity increases, more fluid is pres- 
ent in the lens, and it is this which causes the swelling of the 
lens already referred to. When the whole cortex has be- 
come opaque the fluid contents begin to diminish, and the 
lens returns to its normal size. Senile cataract, then, is en- 
tirely a local process, and is not dependent on any disordered 
state of the general health. 

The dimensions of the nucleus vary a good deal. In some 
cataracts it is very small, and these are called soft cataracts, 
as they consist chiefly of the soft cortical substance. In 
others, and as a rule in patients over sixty years of age, 
the nucleus is large, and these are called hard cataracts, al- 
though they are not hard throughout. The size of the nu- 
cleus can be estimated pretty accurately by the extent and 
intensity of the yellowish or brownish reflection, which is ob- 
tainable by focal illumination out of the center of the cata- 
ract. 

In some senile cataracts the sclerosis is not confined to the 
nucleus, but extends to the cortical layers as well. This 
causes much disturbance of sight, and the term cataracta 
nigra is given to these lenses, from their very dark hue, al- 
though they are not cataracts in the true sense of the term. 
They require operation, and, as they are always of large size, 
wide openings have to be made to deliver them. 

In the lenses of young people there is no nucleus ; conse- 
quently, in the complete cataracts of children and of young 
adults, there is no nucleus ; the whole lens becomes opaque, 
and the cataract is always soft. Although the starting-point 
of cataract in children and young adults cannot be a shrinking 
of the nucleus, as there is none, yet the opacity is no doubt 
due to the taking up of fluid by the lens. 

The symptoms to which senile cataract gives rise consist, 



368 DISEASES OF THE EYE. 

in the earliest stages, in the appearance of motes before the 
eyes and of monocular polyopia. Motes are complained of 
also in disease of the vitreous humor ; but in those cases they 
float over a large portion of the field of vision, while in 
commencing cataract they occupy always the same relative 
position in the field. The polyopia is the result of irregular 
refraction in the media, which causes many images of the ob- 
jects looked at to be formed on the retina. This symptom 
seems to annoy the patients more especially in the evening, 
when they look at gas or candle flames, the moon, etc. It is 
often complained of before there is any actual opacity in the 
lens, at a time when only the clefts filled with fluid between 
the fibrillae can first be detected with weak transmitted light 
as dark lines vanishing and reappearing according as the inci- 
dence of the light is altered. 

In some cases of incipient cataract there is an increase in 
the refracting power of the lens, with the result that the pa- 
tient becomes slightly myopic, if, previously, he has been 
emmetropic. 

Gradually, as the opacity of the lens extends to other parts 
of it, the acuteness of vision becomes affected ; and this is 
the more marked the more the cortex at the anterior and pos- 
terior poles of the lens is involved. In those cases where the 
equatorial parts of the lens are but little affected, while the 
polar regions are a good deal affected, the patients see better 
in the dusk, or with their backs to the light, than when their 
eyes are exposed to a strong light. The reason for this is 
that in the dusk the pupil is dilated, and light can pass 
through the clearer periphery of the lens, while in a strong 
light the pupil is contracted. On the other hand, when the 
opacity is confined rather to the equator of the lens, a strong 
light is not disturbing to sight ; or, if the center of the lens 
be quite clear, a strong light may even be pleasant to the 
patient. 



THE CRYSTALLINE LENS. 369 

But according as the lens becomes more and more opaque 
the acuteness of vision is reduced, until, finall}', even large 
objects cannot be discerned, and only quantitative perception 
of light is left. Some cataracts, when quite ripe, still admit 
of finger-counting at a few feet. 

In advanced stages of the disease, as the opacities occupy 
a great portion of, or the entire cortex, they are easily recog- 
nized even by ordinary daylight, often giving a grayish ap- 
pearance to the pupil. Inflammatory exudation in the area 
of the pupil would afford a somewhat similar appearance, but 
would be attended by other signs of the previous inflammatory 
process, such as synechias, disorganization of the iris, etc., and 
it Avould be seen to lie more in the plane of the iris than does 
any lental opacity. 

The length of time occupied by the ripening of a cataract 
varies in different cases -from a few months to many years. 
In the very old the progress is, in general, more rapid than at 
an earlier time of life. That form which commences at the 
equator as fine lines is slower than that with flocculent 
opacities, or than that in which the cortex around the nucleus 
is likewise implicated at an early period. 

All examinations as to the condition of the lens are ren- 
dered easier and more conclusive if the pupil be previously 
dilated with atropin ; but the tension of the eye should be 
ascertained before atropin is instilled, lest glaucoma, or a 
tendency to it, be present. 

Treatment. — No external local applications, nor internal 
medicines, are of any avail in the treatment of cataract at any 
stage. Removal of the cataract from the eye by operation is 
the only cure for blindness caused by it. 

In cases of incipient cataract, or in those, rather, which 
have advanced somewhat beyond this stage, we often find that 
vision is improved, or made more pleasant, by the wearing of 
tinted glasses to moderate the light. With commencing 



370 DISEASES OF THE EYE. 

cataract where slight myopia has come on, low concave glasses 
for distant vision will be found of service ; while for reading 
stenopeic glasses sometimes give good results. 

Dilatation of the pupil with atropin is in many cases of the 
greatest benefit, especially where the nucleus is much more 
opaque than the cortical portion ; but sometimes the diffusion 
of light resulting is most distressing to the patient, and greater 
impairment and confusion of vision are produced, and for this 
reason care in the prescription of atropin is demanded. 

Patients with incipient or advancing cataract may, with im- 
munity, be allowed to make every use they can of the sight 
they possess ; and the surgeon should give them hints as to 
the arrangement of light in their rooms, and for their work, 
etc., so as to enable them to use their eyes to the best ad- 
vantage. 

The truly distressing period in the progress of cataract, 
when both eyes are affected, lies between the advent of that 
degree of blindness which incapacitates the patient for reading 
or writing, or for making his way about alone, and the occur- 
rence of maturity, or of that degree of maturity which is 
deemed requisite for successful removal. This is often a 
lengthened time ; it may be months or years. Fortunately, in 
many instances one cataract is much more advanced than that 
in the other eye ; and then no such trial need be gone 
through. 

Artificial Ripening. — In order to hasten the maturity of a 
cataract, puncture of its anterior capsule has been proposed 
and practised with success, but has not been generally adopted, 
from the fear that it might set up iritis, and produce increased 
tension from excessive swelling of the cataract. Forster * 
effects artificial ripening by performing an iridectomy, which 
can afterward be utilized for the extraction. This in itself 

* Archives of Ophthalmology, xi, pt. iii, p. 349. 



THE CRYSTALLINE LENS. 371 

often expedites the ripening, probably by disturbing the 
arrangement of the lens-fibers when the aqueous humor flows 
off, and Forster promotes the disturbance by gently rubbing 
or stroking the lens through the cornea immediately after the 
iridectomy with the angle of a strabismus hook. This same 
massage of the crystalline lens may be employed with good 
result after simple tapping of the aqueous humor without 
iridectomy. Soon after this a rapid increase in the opacity is 
often noticed, so that in from four to eight weeks extraction 
can be undertaken. The difficulty of this rubbing or massage 
of the lens lies in the estimation of the pressure to be applied ; 
for if it be excessive the zonula may easily be ruptured, with 
the result of loss of vitreous when the extraction comes to 
be performed. The best results are obtained in cases of 
cataract where there is a firm and somewhat opaque nucleus, 
and where a certain amount of opacity already exists in the 
anterior cortical substance. I occasionally employ the method, 
and with satisfactory results ; but some operators have seen 
iritis follow the proceeding. 

The question whether the cataract in one eye should be 
extracted until both are blind is often asked by patients. The 
answer is : A patient with one mature cataract, and the other 
progressing toward maturity, should have the ripe cataract re- 
moved. Hypermaturity is thus avoided, and also the stage of 
blindness above referred to. Again, if there be a ripe cataract 
in one eye, and not even incipient cataract in the other, it is 
often advisable to operate for the purpose of increasing the 
binocular field of vision. 

Complete Cataract of Young People. — The spontaneous 
occurrence of total cataract in the youthful lens is of rare 
occurrence, and its pathogenesis is still unknown. 

Treatment. — Discission. 

Diabetic Cataract. — This is a complete opacity of the 
crystalline lens occurring in diabetes, and due to disturbed 



372 DISEASES OF THE EYE. 

nutrition. It has been proved by experiment that cataract can 
be produced by injecting solutions of sugar into the blood ; 
but analysis of the aqueous humor in diabetic patients shows 
that the amount of sugar contained in it is not sufficient to 
account for the cataract. The cataract does not differ in 
appearance or consistency from other cataracts, according to 
the time of life of the patient. 

Treatment and Prognosis. — Contrary to a very general 
opinion, these cases are favorable for extraction operations. I 
have operated on several cases of this kind, and always with 
success, save once, when the eye was lost by intraocular 
hemorrhage ; and I have also seen such cases operated on 
successfully by others. There is no other method of restoring 
sight to these patients, who often live a long time. But some 
ophthalmic surgeons of distinction have informed me that 
occasionally patients operated on for diabetic cataract die of 
coma within about a fortnight or so after the operation ; and 
they seemed to think that this was not diabetic coma of the 
ordinary kind, but coma caused in some way by the nervous 
system being upset by the operation. 

The operation of discission in these cases is apt to be followed 
by severe iritis. 

Complete Congenital Cataract. — Children are sometimes 
born with crystalline lenses opaque in all their layers, while 
the other tissues of the eye are healthy. With congenital 
cataract, defects of the choroid or retina or congenital am- 
blyopia without ophthalmoscopic appearances are also some- 
times present, and these are usually indicated by nystagmus. 

Treatment. — Discission. 

Black Cataract. — This name, as above stated, is sometimes 
given to cases of extreme sclerosis of the lens, in which it 
assumes a dark brown color ; but in other cases the lens is 
really black, the pigment being derived from the blood (hemin, 
or hematin). An instance has recently been observed in which 



THE CRYSTALLINE LENS. 373 

the lens was jet-black from this cause. The prognosis in these 
cases is not good, as they are often complicated with disease 
of the choroid, or with hemorrhages in the vitreous humor. 

Partial Cataracts. 

These are nearly all congenital. 

Central Lental Cataract. — This is a congenital and usu- 
ally non-progressive form. It is an opacity of the central or 
oldest lens-fibers, while the peripheral layers remain clear. 

Treatment. — Discission or iridectomy. 

Zonular, or Lamellar, Cataract. — This is congenital or 
forms in early infancy, and is the most common kind of 
cataract in children. It usually is present in both eyes, but 
it has been seen in one eye only. In it the very 
center of the lens is clear (Fig. 103), while around 
this is a cataractous layer or zone, and outside that 
again the peripheral layers are transparent. Most of 
these cases are non-progressive, but occasionally the y\q iox 
whole lens does become opaque, and usually then 
there have been previously some slight opacities in the other- 
wise clear cortical layers. 

With oblique illumination the cortical layers of the lens are 
seen to be clear, while toward the center of the lens a uniform 
gray circular opacity will be observed. The diameter of this 
opacity may be small, perhaps not more than three mm. or 
four mm., or it may extend very nearly to the equator of the 
lens. If the pupil be dilated, and the lens examined with 
transmitted light, the cataractous portion will be seen as a 
more or less dark disc in the center of the lens, while all 
around it is seen the red light reflected from the fundus oculi. 
The center of this disc is either of the same degree of darkness 
as its margin, or but little darker ; and this point serves to 
distinguish this form of cataract from one in which the whole 
center of the lens is opaque. In the latter case it is evident 



374 DISEASES OF THE EYE. 

that the center of the opacity must be darker than its margin. 
In many cases small radial opacities are seen around the equator 
of the lens, passing from the anterior to the posterior surface, 
and their concavity embracing the circumference of the cen- 
tral opacity. 

It is probable that lamellar cataract is due to some transient 
disturbance of nutrition in utero, occurring at the time the 
affected layers of the lens are being laid down. But against 
this view is the fact that one-half of the lens only may present 
the appearance of zonular cataract* The subjects of it are 
usually rickety, as shown by the irregular and imperfect 
development of the teeth, and by rachitic alterations in the 
bones of the skull. Convulsions during infancy in these 
patients are common. 

Tlie treatment of central lental cataract and of zonular cata- 
ract is similar, and consists in either discission or iridectomy. 
The latter is very decidedly to be preferred in those cases in 
which the central opacity is so small that, on dilatation of the 
pupil, the acuteness of vision, with the aid of a stenopeic slit, 
is increased in a satisfactory degree. When the improvement 
is but slight, the breaking up of the lens with a needle is indi- 
cated. The advantage of iridectomy over discission, when the 
former can be adopted, is that no spectacles are afterward 
required, and that the power of accommodation is retained. 

Congenital cataracts may be needled any time after denti- 
tion is completed. 

Anterior polar, or pyramidal, cataract may be either 
congenital or acquired. In the former case it must be referred 
to some inflammatory disturbance occurring about the third 
period of development of the lens. In both cases the mode of 
origin of the opacity is the same, whether it be punctifogn, 
flakelike, or pyramidal — namely, by contact of the lens with 

* Centralblatt f. p7'ak. Augenheilkunde, 1 894, p. ZZ- 



THE CRYSTALLINE LENS. 375 

an inflamed cornea. In fetal life this may occur without any 
perforation of the cornea, as there is then no anterior chamber. 
After birth a perforating ulcer of the cornea is a necessary 
precursor of it, but the ulcer need not be central (p. 134). 
This contact with an inflamed and ulcerating cornea may lead 
to subcapsular cell-proliferation at that portion of the capsule 
which is exposed in the pupillary area. 

No treatnie7it is required, as vision is not affected. 

Fusiform, or spindle-shaped, cataract is also congenital, 
and is rare. It consists in an axial opacity extending from 
pole to pole, and may be combined with central or lamellar 
opacity. 

The foregoing forms of cataract, with the exception, perhaps, 
of the pyramidal and genuine black cataract, are primary ; that 
is to say, they are not dependent on, or the result of, disease 
in other parts of the eye. 

But the fact has to be recognized that some diseased states 
of the eye give rise to 

Secondary Cataract. 

Of this a partial kind is : 

Posterior Polar Cataract. — This form is seen, with trans- 
mitted light, as a star-shaped or rose-shaped opacity in the 
most posterior layers of the posterior cortical substance, its 
center corresponding with the posterior pole of the eye. 

Posterior polar cataract is usually found in eyes which are 
the subjects of disseminated choroiditis, retinitis pigmentosa, 
or diseased vitreous humor. It sometimes progresses, and 
becomes a complete cataract ; and then the prognosis for 
sight after extraction is not very good, owing to the disease 
which is present in the deep parts of the eye. 

The additional disturbance of sight caused by the presence 
of posterior polar cataract depends a good deal upon its density. 

Total secondary cataract often ensues upon contact of 



376 DISEASES OF THE EYE. 

the lens with inflammatory products in the eye — <^'-g., where 
false membranes have been produced by inflammation in the 
uveal tract. It is sometimes then called Cataracta accreta, 
when the iris or ciliary processes are adherent to it. Cataract 
is also caused by detachment of the retina, intraocular tumor, 
absolute glaucoma, dislocation of the lens, etc. The reason of 
this is that the lens, in these cases, imbibes abnormal nutrient 
fluid from the diseased tissues with which it is in contact. 

Such cataracts often undergo a further degeneration, and 
become calcareous. Calcareous cataracts are easily recognized 
by their densely white or yellowish white appearance ; and 
almost always indicate deep-seated disease in the eye, even 
when the functions, so far as they can be tested, are fairly 
good. 

These secondary cataracts rarely come within the range of 
treatment, as the diseases which give rise to them are usually 
destructive of sight. When, occasionally, they can be dealt 
with, they should be extracted. 

The term secondary cataract is also used in cases in which, 
after a cataract extraction, the capsule of the crystalline lens, 
which is left behind, presents an obstacle to good sight. This 
will be referred to again further on, and is not to be classed 
with the conditions dealt with in this paragraph. 

Capsular Cataract 
means an opacity of the anterior capsule or of the capsular 
epithelium. It is usually confined to the center or anterior 
pole, and is most frequently seen in over-ripe senile cataracts 
and in secondary cataracts. 

Traumatic Cataract. 
Every injury which opens the capsule of the lens is liable to 
cause cataract, by reason of the admission of some of the sur- 
rounding fluids to the lenticular substance. 



THE CRYSTALLINE LENS. 377 

Perforating injuries with sharp instruments, or the entrance 
of small foreign bodies — in both cases, as a rule, through the 
cornea — are the most common injuries that produce traumatic 
cataract. But blows upon the eye, without any perforating 
wound, also, although rarely, produce cataract. In these 
latter cases there is a rupture of the capsule, either at the 
equator of the lens, or on its posterior or anterior surface. 

Within a few hours after a perforating injury of the anterior 
capsule, the lens substance in the immediate neighborhood of 
the opening becomes opaque, swells, and protrudes as a gray 
fluffy-looking mass, through the opening and into the anterior 
chamber, where it breaks up, dissolves, and becomes absorbed. 
It is immediately followed by other portions of the lens which 
have become cataractous, until, gradually, the whole lens may 
have disappeared, and the pupil again become black. Marcus 
Gunn suggests * that the explanation of the solution of the 
cataract in the anterior chamber consists in the fact that glob- 
ulin is normally soluble in a weak solution of chlorid of sodium, 
such as we have in the fluid of the anterior chamber. The 
absorption of a traumatic cataract takes many weeks ; and 
ultimately the eye sees well if a suitable convex lens be put 
before it. 

But the course of events just sketched is the most favorable 
one, and is hardly likely to take place in a case which is 
wholly untreated. In the first place, the swelling of the lens 
— especially if it be rapid, in consequence of a wide opening 
in the capsule — is liable to irritate the iris, and to cause iritis ; 
or to push the periphery of the iris forward against the per- 
iphery of the cornea, block the angle of the anterior chamber, 
and cause secondary glaucoma (p. 361). 

Moreover, violent plastic or purulent uveitis may come on, 
as the consequence of the introduction of infective matter on 

* Ophthalmic Review^ 1889, p. 235. 
32 



378 DISEASES OF THE EYE. 

the perforating object, or foreign body, which causes the cata- 
ract. Where this occurs, the case enters into the category 
of diseases of the uveal tract ; and the cataract, as such, be- 
comes a minor consideration. 

Again, we sometimes meet with traumatic cataracts which 
do not undergo any absorption process, but simply remain 
stationary ; or, in the course of years, undergo secondary 
changes similar to those which occur in senile cataract. In 
these instances the trauma is usually a blow on the eye, not 
a perforating injury ; and it is believed that the rupture of 
the capsule closes soon after the blow, and hence no lens 
matter can escape into the anterior chamber ; also, the rupture 
in many of these cases is probably at the equator of the lens, 
where the aqueous would not readily get access to the lentic- 
ular substance. 

Where the cataract is produced by a small foreign body 
flying through the cornea and into the lens, it is a matter of 
importance for the prognosis to decide whether the foreign 
body be in the lens or has passed through it into the deeper 
parts of the eye. In the former case we may hope to extract 
it with the cataractous lens ; while in the latter case we must 
fear that it will set up dangerous inflammatory reaction. In 
such cases the lens should be well searched with focal illumina- 
tion, and the transmitted light may also be of use; but it 
must be remembered that in these traumatic cataracts there 
are often glittering sectors in their deep parts, which may 
readily be mistaken for a metallic foreign body. 

Treatment. — The pupil should be kept dilated with atropin, 
in order to draw the iris out of the way of the swelling lens 
matter ; and nothing more is necessary if complications do 
not arise. But should iritis or high tension come on — and 
the surgeon must constantly test the tension — it is important, 
without further delay, to extract as much as possible of the 
cataract. This may be done either without an iridectomy, 



THE CRYSTALLINE LENS. 379 

through a Hnear incision some ten mm. long in the upper third 
of the cornea, or with an iridectomy, through an incision in 
the upper margin of the cornea. 

If a foreign body be present in the lens, extraction of the 
latter with the foreign body should invariably be undertaken. 

Where violent purulent or plastic uveitis is set up by the 
trauma, the treatment resolves itself into that for these inflam- 
mations. 

Operations for Cataract. 

With regard to the state of health of the patient about to be 
operated on, it is desirable, as in every operation, that it should 
be good. Still, we have so often in these cases to deal with 
very old people that we cannot in every instance require sound 
organs and a robust constitution ; and, as a matter of ex- 
perience, I have not found serious disease of the heart, lungs, 
and liver, even when they all existed in the same individual, any 
impediment to a successful operation. Diabetes is no abso- 
lute contraindication, and even in the presence of Bright' s 
disease I have operated successfully. Very advanced years 
form no obstacle. I have frequently operated for cataract on 
persons over eighty years of age, and ahvays with success. 

Tlie state of the eye itself should be carefully investigated 
prior to proposing or undertaking an operation for cataract, 
and is a much more important matter than the general health. 
Above all things, it is to be determined whether there be in- 
traocular complications, which would neutralize the result of 
a successful operation, such as detachment of the retina, dis- 
seminated choroiditis, atrophy of the optic nerve, etc. The 
examination of the eye in question before the lens has become 
opaque, if the surgeon has had that opportunity, will be the 
most reliable basis upon which to go ; and for this reason a 
careful note should be taken of the condition of the fundus in 
each case of incipient cataract. The examination of the fun- 



38o DISEASES OF THE EYE. 

dus of the other eye, if its lens be clear, may help in deter- 
mining the point, in so far as those intraocular diseases are con- 
cerned which are apt to be binocular. Again, the condition 
of the anterior capsule of the lens should be observed, for a 
defined glistening white square patch, about two mm. broad, 
situated in the center of the capsule, tells the tale of intraocu- 
lar mischief It cannot be confounded with the more diffused 
striated and punctated capsular alterations due to over- 
ripeness. 

Finally, the functions of the eye should be examined. 
With an uncomplicated cataract of the most opaque kind 
good perception of light should be present, so that the light, 
say, of a candle some two meters distant may be distinguished. 
In less dense cataracts, fingers may be counted at i m. or 
1.5 m., when full maturity has been attained. The field of 
vision must be examined by means of the "projection of 
light " — /. e., a Hghted candle held in different parts of the 
field should be recognized by the patient, who is required to 
point his finger in the direction of the light as it is moved 
rapidly from one part of the field to another. This examina- 
tion can also be made by means of the light reflected from 
the ophthalmoscope mirror. If the patient fail to project the 
light in any direction, a diseased condition in the correspond- 
ing part of the retina may be suspected. In cases of very 
old uncomplicated cataract the patients often project the light 
in one direction, no matter where it may come from. A cer- 
tain degree of intelligence on the part of the patient is re- 
quired for this test. 

By the foregoing means most intraocular complications of 
a serious nature can be detected ; but there is at least one 
against which I know of no safeguard, namely, a small 
circumscribed spot of choroidoretinal degeneration at the 
macula lutea (central senile choroiditis). After removal of a 
cataract from an eye affected in this way, the patient's vision is 



THE CRYSTALLINE LENS. 381 

SO much improved as to enable him to go about alone, but 
reading will still remain an impossibility for him. 

TJie Cornea Should be Examined. — Such corneal opacities as 
would seriously compromise vision may contraindicate the 
operation ; but slighter opacities, discernible only with oblique 
illumination, would merely diminish the future acuteness of 
vision, and would require a corresponding prognosis to be 
given before operation. 

The condition of the appendages of the eye, too, must be 
examined. Should there be any conjunctivitis, blepharitis, or 
dacryocystitis, it ought to be cured or alleviated before the 
operation is undertaken. Very successful operations may be 
performed in the presence of chronic dacryocystitis or granular 
ophthalmia ; but it is in all respects wiser to reduce their 
activity to a minimum. Some surgeons, in cases of dacryo- 
cystitis, temporarily obliterate the lacrimal puncta by introduc- 
ing a red-hot needle. 

Extraction of Cataract. 

Linear Extraction. — The extraction through a linear in- 
cision in the cornea is applicable only to soft or fluid cataracts, 
in persons up to the age of twenty-five. The instruments 
required are : A spring-hd elevator (Fig. 104), a fixation 
forceps, a wide lance-shaped iridectomy knife (Fig. 105), a 
cystotome (Fig. 106), and a Critchett's vectis (Fig. 107). 

The speculum having been applied, a fold of conjunctiva 
close to the margin of the cornea and at the inner end of the 
horizontal meridian of the. latter, is seized (Fig. 108) with the 
fixation forceps, and the eye fixed by it throughout the opera- 
tion. The point of the knife is now entered into the cornea 
in its horizontal meridian, about four mm. from its outer 
margin, and is passed into the anterior chamber. The blade 
of the knife is then laid in a plane parallel to that of the iris, 
and pushed on until the corneal incision has attained a length 



382 



DISEASES OF THE EYE. 



of six or seven mm. The point of the knife being now- 
laid close to the posterior surface of the cornea — in order 
that no injury may be done to the iris or lens when the aque- 




FiG. 104. 

ous humor commences to flow off — the instrument is very 
slowly withdrawn, so that the aqueous humor may come away 
gradually, without causing prolapse of the iris. In withdraw- 





F1G.105. 



Fig. 106. 



Fig. 107. 



ing the knife, it is well to enlarge the inner aspect of one or 

other end of the wound by a suitable motion of the instru- 
ment in that direction. 

The knife being now put aside, the cystotome is passed 



THE CRYSTALLINE LENS. 



383 



into the anterior chamber (Fig. 109) as far as the opposite 
pupillaiy margin, care being taken, by keeping the sharp point 
of the instrument directed either up or down, not to entangle 
it in the wound or in the iris. The point is now turned 
directly on the anterior capsule, and, by withdrawing the cys- 




FiG. 108. 



totome toward the corneal incision, an opening in the capsule 
of the width of the pupil is produced. The cystotome is then 
removed from the anterior chamber, with the same precautions 
as on its entrance. 

The edge of the vectis is then placed on the outer lip of the 
corneal incision, and the latter is made to gape somewhat, 




P^IG. 109. 



gentle pressure being at the same time applied to the inner 
aspect of the eye by the fixation forceps, and in this way the 
lens is evacuated. When the pupil has become quite black 
the operation is concluded. If pressure does not at first clear 
the pupil completely, the speculum should be removed, the 



384 



DISEASES OF THE EYE. 



eyelids closed, a compress applied, and a few minutes allowed 
to elapse, in order that some aqueous humor may be secreted. 
A renewal of the efforts to clear the pupil will probably now 
be successful, or, if not, another pause may be made, and then 
fresh attempts employed until the pupil is quite clear. It is 
unwise to insert the vectis into the eye to withdraw the frag- 
ments ; and if some of these should be left behind, no ill results 
need necessarily follow, although iritis is more apt to supervene 
than if the lens be thoroughly evacuated. Fragments left be 
hind become absorbed. If there be a prolapse of the iris 
which cannot be reposed it must be abscised. 

Von Graefe, Waldau (Schuft), and Critchett endeavored, 
by increasing the size of the incision, placing it in the corneo- 
sclerotic margin, performing an iridectomy, and introducing a 
vectis for delivery of the cataract, to make the linear extrac- 
tion applicable to senile cataracts. The successes derived 
from these modifications were not, however, more satisfactory 
than those obtained from the old flap-operation. But these 
experiments led von Graefe to the operation, a modification 
of which is now very generally employed. He called his 
operation : 

The Modified Peripheral Linear Extraction. — The in- 
struments required are : A wire lid-speculum, a fixation 
forceps with spring catch, a von Graefe' s cataract knife 
(Fig. iio), a curved iris forceps, iris scissors, or de Wecker's 
forceps-scissors (Fig. iii), a bent cystotome, a hard-rubber 
spoon (Fig. 112), and a hard-rubber, tortoise-shell, or silver 
spatula (Fig. 1 13). 

Before proceeding to operate, the eye is nowadays thor- 
oughly cocainized by the instillation of about three drops of 
a two per cent, solution of hydrochlorate of cocain, at in- 
tervals of two or three minutes. Previously to the introduc- 
tion of cocain general anesthesia wath ether or chloroform 
was commonly employed in England. I never used it. 



THE CRYSTALLINE LENS. 



385 



Fig. 1 10. 



Fig. III. 



Fig. 112. Fig. 113. 



386 DISEASES OF THE EYE. 

Antiseptic measures, similar to those used for the three 
milhmeter flap-operation (inde infra) are to be carefully at- 
tended to. 

The Operation. — The speculum having been applied, the 
eye is steadied by seizing a fold of conjunctiva, with its sub- 
conjunctival tissue, close to the lower margin of the cornea, 
and in a prolongation of the vertical meridian of the latter. 
The eye is now drawn gently downward, the patient assisting 
in the motion. The point of the Graefe's knife, its cutting 
edge being directed upward, is then entered into the corneo- 
sclerotic margin at a point (^A in Fig. 114) about 1.5 m. from 
the outer and upper corneal margin, and tw^o mm. below the 
level of the tangent which would pass through the highest 
point of the corneal margin. The blade is held in a plane 
parallel to that of the iris, and is pushed on into the anterior 
chamber until its point reaches the point C, 
some seven or eight mm. of the blade being 
now in the anterior chamber. The handle of 
the knife is then lowered, so that the point of 
the blade is brought up to B^ where it is made 
to pass out through the corneosclerotic mar- 
gin, this counterpuncture corresponding in position, with refer- 
ence to the corneal margin, to the point of entrance A. The 
edge of the knife is now turned slightly forward, and by one 
or tw^o sawing motions the incision A B is completed in the 
corneosclerotic margin. The blade still lies under the con- 
junctiva, which is divided, the edge of the instrument being 
turned more forward, or even somewhat downward, as it is 
not desirable to have too large a conjunctival flap. 

The advantage of this incision lies in its peripheral position, 
which is almost in the plane of the crystalline lens, and 
consequently enables the cataract to be delivered without 
revolution on its axis. At a later period von Graefe altered 
the incision, so that, puncture and counterpuncture lying as 




THE CRYSTALLINE LENS. 387 

described, the center of the incision passed through the apex 
of the clear cornea instead of through the corneosclerotic 
margin. This, by making the incision more nearly a segment 
of a greater circle of a sphere, made it as linear as possible, 
and consequently, in his opinion, its margins adapted them- 
selves more readily. 

The next step in the operation is an iridectomy, a portion 
of iris corresponding to the whole length of the wound, or 
nearly as much, being excised. This iridectomy is necessar}% 
or advisable, chiefly because of the peripheral position of the 
wound, which would render prolapse of the iris very liable to 
occur, but it also facilitates the delivery of the lens and cortical 
masses. The subsequent stages — capsulotomy and delivery 
of the lens — are similar in their details to those in the three 
millimeter flap-operation, to be presently described. 

It was found that the advantages of the position and form 
of the incision in this procedure were largely counterbalanced 
by the danger of prolapse of the vitreous, the difficulty of 
proper reposition of the angles of the coloboma, and the liability 
to cyclitis, all entailed by the peripheral incision, and conse- 
quently this incision has been abandoned by nearly all opera- 
tors. 

Out of this method grew that one which is known as the 
three millimeter flap-operation, first proposed by de Wecker. 
I shall describe the operation as I am in the habit of perform- 
ing it ; and I may here say that for success in the cataract 
operation it is necessar\^, not only to select the method which 
seems the most rational, but also to devote the utmost attention 
to a series of minute details in its performance. 

Preparation of the Patient. — A gentle purgative is given the 
day before the operation, so that the bowels need not be dis- 
turbed for two days after the operation. In the case of hospital 
patients, the face is washed with hot water and soap shortly 
before the operation. 



388 DISEASES OF THE EYE. 

Preparation of the Eye. — Half an hour before the operation 
a drop of a two per cent, solution of sulphate of eserin (made 
with a I : 5000 solution of corrosive sublimate) is dropped 
into the eye, and this is repeated a quarter of an hour later. 
Just before the operation, at intervals of two minutes, three 
drops of a two per cent, solution (made with corrosive subli- 
mate solution) of muriate of cocain are dropped into the eye. 
Finally, the lids having been everted, the conjunctival sac is 
washed out with solution of corrosive sublimate, i : 10,000, 
particular attention being paid to the fornix of each lid and to 
the inner and outer canthus. Then the skin of the eyelids and 
immediate surroundings of the eye are freely washed with the 
same solution. 

Preparation of the Instruments. — The instruments required 
are the same as those for the modified linear extraction. Im- 
mediately before the operation they are sterilized by boiling ; 
out of the boiling water they are plunged for a moment into 
absolute alcohol, and then laid in a bath of a i : 2300 solution 
of hydronaphtol until required for use. 

During the progress of the operation small bits of lint, wet 
with the I : 10,000 sublimate lotion, are employed to wipe 
away coagula, cortical masses, etc., and are not employed a 
second time. An assistant should place the instruments in 
the surgeon's hand in their turn, and take out of his hand those 
he has used, in such a manner as to render it unnecessary for 
him to look away, even for a moment, from the field of opera- 
tion. 

The Operation. — A spring wire lid-speculum is applied. The 
eye is fixed with a catch fixation forceps by a fold of con- 
junctiva and subconjunctival tissue, below the vertical meridian 
of the cornea, or a little to one side of this line (Fig. 1 15). 

The point of the knife is entered just in the margin of the 
clear cornea, at the outer extremity of a horizontal line which 
would pass three mm. below the summit of the cornea. This 



THE CRYSTALLINE LENS. 



389 



line is easily found by placing the knife, which is about two 
mm. broad, horizontally across the cornea, so that a margin of 
clear corneal tissue one mm. broad may remain exposed be- 
tween the knife and the summit of the cornea. The knife is 
then passed cautiously through the anterior chamber, and the 
counterpuncture made in the corneal margin at the inner 
extremity of the horizontal line described, and the incision 
finished in the corneal margin by a few slow to-and-fro motions 
of the knife. 

Owing to the action of the eserin, the iris does not prolapse. 
The incision, between puncture and counterpuncture, lies in 




Fig. 115. 



the clear cornea at its very margin, as represented by the 
dotted line in figure 115. This incision is no longer linear, 
but slightly curved. It is found, however, to adapt itself 
readily, and, being less peripheral than the true von Graefe 
incision, the objections to the latter are obviated. 

The second stage of the operation consists in an iridectomy. 
The fixation of the eye having been given over to the assistant, 
the iridectomy is performed by passing a curved iris forceps 
into the anterior chamber, seizing the smallest possible portion 
of the sphincter of the iris at a point corresponding to the 



390 DISEASES OF THE EYE. 

center of the incision, drawing it out, and with the forceps- 
scissors excising a very small central bit of iris. This is done 
either by making two snips in the iris, one at either side of 
and close to the forceps, each of them reaching to the periphery 
of the iris, and then a third cut which joins these two at the 
base ; or, the forceps-scissors being approached from over the 
cornea, the coloboma may be formed with one snip of the in- 
strument, and, if care be taken to keep the blades close to the 
forceps, a narrow, neat coloboma may thus be obtained. It is 
unnecessary to excise a large portion of iris, although in von 
Graefe's original operation a portion corresponding to the 
entire length of the wound used to be taken away. A small 
coloboma, say of two mm. to three mm. in width, as in figure 
95, is sufficient to allow of an easy delivery of the lens by 
doing away with the resistance of the sphincter iridis, and to 
prevent secondary prolapse of the iris {inde infra) ; and its 
advantages over a wide iridectomy, from an esthetic point of 
view, are obvious. It is always, therefore, my object to obtain 
the smallest possible coloboma. The procuring of a neat colo- 
boma is much facilitated if, prior to the operation, the pupil 
has been contracted (see Fig. 115) by the instillation of one 
or two drops of solution of sulphate of eserin, as above 
recommended. 

The third stage of the operation is the capsulotomy. The 
operator takes the fixation forceps from his assistant, who 
then raises the speculum and eyelids slightly off the globe, 
in order that no pressure may be exerted on the latter during 
the remainder of the operation. The surgeon, passing the 
cystotome into the anterior chamber, divides the anterior 
capsule of the lens by two incisions, each from the lower 
pupillary margin upward, one directed outward, the other 
inward, as far as the anterior surface of the lens can be seen, 
while finally a third incision is made along the upper periphery 
of the lens. An extensive opening in the capsule is of great 



THE CRYSTALLINE LENS. 391 

importance, as otherwise difidculty in delivery of the lens may 
be experienced, and because a small opening renders the 
occurrence of secondary cataract more likely. In dividing 
the capsule it is important not to dig into the lens, as this, in 
the case of a hard cataract, is apt to dislocate it. A rather 
oblique application of the cystotome to the capsule is, for this 
reason, the best. 

The cystotome often drags a tag of the capsule into the 
corneal wound, where it lies until the end of the operation, 
and where, owing to its transparency, it may easily pass 
unnoticed. Such a tag acts as a foreign body, and may 
subsequently form the starting-point of troublesome compli- 
cations. 

Capsule forceps have been invented for the purpose of taking 
away a large portion of the anterior capsule ; but this does 
not altogether obviate the danger of capsule in the wound, 
nor does it do away with the likelihood of secondary cataract. 
I have no objection to the method, but it does not seem to 
have any advantages over that just described in cases where 
the capsule is not thickened. But when the anterior capsule 
is thickened, it is always desirable to tear away a central portion 
of it with forceps. 

Gayet, of Lyons,* and Knapp, of New York,f have proposed 
a method of opening the capsule termed peripheral division — 
i. e., they make only one opening in the capsule at the upper 
periphery of the lens with a very sharp needle cystotome, 
which is passed along the whole length of the corneal section, 
a wide iridectomy having been made for this purpose. The 
chief advantages claimed for this method are : Safety from a 
tag of capsule in the wound, and safety from iritis caused by 
irritation from particles of lenticular substances left behind 

* Gazette Hebdoiiiadaire, 1875, No. 35. 

f Archives of Ophthalmology and Otology, Vol. vi, p. 545. 



392 DISEASES OF THE EYE. 

after delivery of the lens. On the other hand, it has the 
disadvantages of the wide iridectomy, and of the secondary 
operation on the capsule, which is necessary in a large propor- 
tion of the cases. 

The fourth stage is the delivery of the cataract. The eye 
is drawn gently downward, the patient being called on to 
assist in this motion by looking toward his feet ; the convex 
edge of the hard-rubber spoon is placed just below the lower 
edge of the cornea, and gentle pressure is exercised on this 
place, the pressure to be gradually increased until the upper 
margin of the lens presents itself in the wound, when, the 
same pressure being maintained, the spoon is advanced over 
the cornea in an upward direction, pushing the lens before it 
and out through the wound. As soon as the greatest diameter 
of the lens has passed the wound the pressure of the spoon 
should at once be diminished, lest rupture of the zonula be 
caused. The fixation forceps and speculum are now removed 
from the eye, and a cold compress with sublimate lotion is 
laid on the closed lids. 

The fifth stage consists in freeing the pupil of any cortical 
masses which may have been rubbed off in the passage of 
the lens through the wound, and in what is called the toilet 
of the wound. 

The presence of cortical remains is recognized by the pupil 
not having become quite black, or by the vision not being 
such as it ought to be (fingers counted at several feet), or by 
inspection of the cataract just removed showing that some 
portions of it are left behind. The use, also, of focal electric 
illumination for the detection of cortical fragments is very ad- 
vantageous. If any fragments be present, the cold antiseptic 
compress having lain on the eye for a few minutes to enable 
some aqueous humor to collect, the operator, facing the 
patient, raises the upper lid with the thumb of one hand, 
while, with the first and second fingers of the other laid on 



THE CRYSTALLINE LEXS. 393 

the lower lid, light rotator}- motions are made with this lid 
over the cornea so as to collect the masses toward the pupil, 
and then a few rapid Hght motions upward, with the margin 
of the lid, drive these masses toward and out of the wound. 

Care and delicacy of touch are required in order to perform 
this lid-manoeuver successfully, without rupturing the hyaloid 
by undue pressure. 

With an iris forceps the blood-clots which may adhere to 
the wound are now removed. 

I then invariably employ the following means, to prevent 
the possibility of any portion of capsule being incarcerated in 
the wound during healing : A bent iris forceps is passed open 
between the lips of the wound, closed, and drawn gently out 
again. Frequently a tag of capsule will have been captured 
by the forceps, and is snipped off with the scissors, or it may 
be that no capsule is caught. The forceps is then similarly 
inserted at an adjacent part of the wound ; and in this manner 
the wound is searched from end to end for capsule. In about 
25 per cent, of the cases a tag of capsule is found present. I 
regard this measure, which I am not aware that any other sur- 
geon has previously recommended, as an important one, for I 
believe that it effectually removes the one serious drawback to 
the valuable operation under consideration. 

Finall}-, the coloboma has to be seen to. The peripheral 
portions of the iris corresponding to the ends of the wound 
are apt to have become prolapsed in the course of the opera- 
tion, and to have displaced the angles of the coloboma up- 
ward. If this be not corrected, the prolapsed portions of the 
iris heal in the wound, and cause bulgings there later on, the 
pupil in the course of some months becoming drawn up toward 
the cicatrix. Hence, in even' case, even where everything 
seems to be in order, it is important to pass the narrow 
spatula into the anterior chamber, and to gently stroke down 
each pillar of the coloboma as far as it can be brought. The 
33 



394 DISEASES OF THE EYE. 

instillation of eserin before the commencement of the operation 
will cause the sphincter iridis to assist in producing the desired 
result. All this is aptly termed the toilet of the wound. 

The sight of the eye should then be tested by finger-count- 
ing, as this affords the patient satisfaction, and lends him 
courage for the next few days of strict quiet. 

Having secured the required advantage from the effect of 
the eserin, a drop of atropinis put into the eye before applying 
the bandage, in order to do away with the miosis, which 
might give a tendency to iritis. 

The dressing is now applied. A piece of lint, sufficiently 
large to extend yl of an inch beyond the orbital margin in 
every direction, is soaked in a solution of corrosive sublimate 
(i : 5000) and laid on the closed eyelids. Pledgets of ab- 
sorbent cotton-wool, soaked in the same solution, are laid on 
this, the hollows at the inner canthus, etc., being carefully 
filled up ; so that, when the bandage is put on, it may exert 
equal pressure on every part of the eye. Over all comes a 
layer of oiled silk protective. I apply three turns of a narrow 
flannel roller over the dressing and around the head, in the 
manner which was customary in von Graefe's clinic ; but 
various other, and doubtless equally good, forms of bandage 
are in use. The pressure of the bandage need only be 
sufficient to maintain the dressing firmly in its place. It is 
usual to keep the other eye closed by a light bandage. 

I am opposed to the after-treatment of cataract operations 
without bandage, as advocated by some surgeons. It is by no 
means a new method, and I do not doubt that many cases 
recover under it. I do not believe, however, that in a long 
series of cases the same percentage of recoveries can be ob- 
tained by it as with the bandage. 

Accidents Liable to Occiir Duj'ing the Operation. — The wound 
may be made too small. The delivery of the lens, con- 
sequently, may be so difficult that the margins of the wound 



THE CRYSTALLINE LENS. 395 

are contused, and then suppuration may be promoted. The 
zonula, too, may be ruptured by the excessive pressure from 
efforts to force the lens out, and prolapse of the vitreous may 
ensue. If the directions above given be carefully attended to, 
the vast majority of both hard and soft cataracts may be ex- 
tracted without difficulty ; but should the wound be made too 
small it can best be enlarged by the forceps-scissors, or a 
blunt-pointed knife made for the purpose. Where the presence 
of an unusually large hard cataract is diagnosed, it is important 
to make the incision larger ab initio by placing puncture and 
counterpuncture nearer to the horizontal meridian of the cornea 
than above directed. 

Hemorrhage into the anterior chamber may take place. It 
may be from the iris, from the corneosclerotic margin, or from 
the conjunctiva. Pressure with the spatula on the cornea, 
which causes the wound to gape, is often successful in clearing 
the chamber of blood, which might interfere with accurate 
division of the capsule. Yet when this cannot be completely 
got rid of the capsulotomy may be performed with the exercise 
of greater care. Cocain, by its power to contract the blood- 
vessels, has rendered this hemorrhage a less common compH- 
cation than it used to be. 

Prolapse of the Vitreous Humor. — This may be due to a 
too peripheral position of the wound, support being thus 
taken away from the zonula, and the danger of its occurrence 
was a disadvantage of the completely corneosclerotic w^ound 
practised at one time by von Graefe. The three millimeter 
flap-operation is less liable to be attended with loss of vitreous. 
This accident may also be caused by undue pressure made on 
the eyeball by the speculum, fixation forceps, or spoon, or by 
the under lid during the lid manceuver. It may be due to 
defective zonula Avith fluid vitreous humor. When the vitreous 
prolapses prior to delivery of the lens, the latter falls back into 
the eye, and can only be delivered by at once drawing it out 



396 DISEASES OF THE EYE. 

with a Critchett's, Taylor's, or other suitable vectis ; and this 
may be regarded as one of the most serious accidents which 
can occur in the course of the operation. Loss of vitreous 
after delivery of the lens is less serious ; indeed, a considerable 
portion of the vitreous may then be lost without ill result to 
the eye ; yet it increases the traumatism, and renders inflam- 
matory reaction more liable to occur. Opacities in the pos- 
terior chamber of the eye are frequently an ultimate result of 
loss of vitreous ; but a much more serious consequence is 
sometimes seen in detachment of the retina. 

Normal After-progress. — Soon after the completion of a 
normal operation, the effect of the cocain having passed off, 
some smarting commences, and continues for four or five hours. 
After that time the patient has no unpleasant sensation in the 
eye, unless it be some itching, or a slight momentary "pain or 
sensation of a foreign body, especially when the eye is moved 
under the bandage. The first dressing is made in forty-eight 
hours, in a manner similar to that immediately after the opera- 
tion, a drop of atropin being instilled, as also at each successive 
dressing ; and the corrosive sublimate solution is used for 
freely washing the margins of the eyelids, some of it being- 
allowed to trickle into the conjunctival sac. At this first 
dressing it is well to abstain from a minute or lengthened 
examination of the eye ; but if the lid be gently raised, the 
wound will be found closed, the cornea clear, the anterior 
chamber completely restored, and the pupil semi-dilated and 
black. The subsequent dressings are made night and morn- 
ing, for the purpose of instilling atropin. On the third day 
after the operation the patient may be allowed to sit up, the 
room being kept moderately dark ; and on the fifth or sixth 
day the bandage may be left aside permanently, and dark 
glasses worn in its stead. In the course of a few days more 
the patient, having been gradually used to more light, may be 
allowed out-of-doors. It is desirable to continue the use of 



THE CRYSTALLINE LENS. 397 

atropin for about a fortnight longer, or until all abnormal 
vascular injection of the white of the eye has disappeared, as 
until then there is danger of iritis. (For selection of glasses 
in aphakia see end of this chapter.) 

Irregularities in the Process of Healing. — The pain may con- 
tinue longer than four or five hours, and it is then well to quiet 
it by a hypodermic injection of morphin in the corresponding 
temple. Should severe pain come on some hours later it is 
apt to be due to an accumulation of tears under the eyelids, 
and it immediately subsides on the bandage being removed and 
exit given to the tears by slightly opening the eye. Antiseptic 
precautions are to be observed while this is being done. 

Late Appearance of the Anterior Chamber. — At the first 
dressing it will sometimes be found that there is no anterior 
chamber, although the appearance of the wound is quite 
satisfactory ; but this need occasion no alarm, as the anterior 
chamber is sometimes not restored for a week or more. 

Striped Keratitis. — At this dressing, also, it may be ob- 
served that there is a more or less w^ell-marked striated 
cloudiness of the cornea, extending over nearly the whole of 
it, or occupying only a part in the immediate neighborhood 
of the wound. 

This opacity is, according to some, the result of injury to 
the endothelium of the posterior surface of the cornea during 
the operation by instruments, or by the chemic action of the 
antiseptic lotion. Leber has shown that the entrance of even 
the aqueous humor, through a loss of substance in the endo- 
thelium, is sufficient to cause the fibers of the true cornea to 
swell and become opaque, just as the crystalline lens is acted 
on if its capsule be opened. The endothelium of the posterior 
surface of the cornea in fact it is, which protects the latter 
from being infiltrated by the aqueous humor. 

The explanation given by Hess,* however, seems a very 

'^Von Graefe^ s Archiv, xxxviii, iv. 



398 DISEASES OF THE EYE. 

reasonable one, namely, that it is due to folding of the poste- 
rior layers of the cornea, on account of the difference in ten- 
sion in the vertical and horizontal direction. His conclusions 
are based on microscopic examination and experiment. 

This so-called striped keratitis is, for the most part, of no 
serious import, as it usually passes away in a few days, and 
leaves the cornea perfectly clear ; and folding of the posterior 
layers would account for these cases. But now and then 
cases do occur in which the process is very intense, and where 
a permanent white opacity remains in the cornea over the 
pupillary area, with consequent serious deterioration of vision. 
These severe cases are most apt to be caused by the intro- 
duction of the antiseptic solution into the anterior chamber ; 
for the chemic action of the antiseptic on the corneal tissues 
is more damaging, and, therefore, the opacity it produces 
more permanent, than is the action of the aqueous humor. 
Sublimate lotion is the antiseptic which has been most often 
to blame, probably because it is the antiseptic in most general 
use. With the i : 5000 solution which I have until recently 
employed, I never had the severe form, and rarely the mild 
form ; but then I never deliberately introduced the solution 
into the anterior chamber. I have had only one case of the 
severe form, and in it, by mistake, a sublimate lotion of 
I : 2500 was used for irrigation of the surface of the eye. 
As stated above, I now employ a solution of only i : 10,000. 
No doubt, in irrigation of the surface of the eye, some of the 
lotion used is liable to make its way into the anterior cham- 
ber. Boric acid solutions (three per cent.) do not injure the 
endothelium, but I have little faith in their antiseptic proper- 
ties. 

Suppuration of the Wound. — This is a danger which is very 
much rarer than it was prior to the introduction of antiseptics 
into surgery ; indeed, it is almost banished from the cataract 
operation. When it occurs it usually does so between the 
twelfth and thirty-sixth hour after the operation, rarely earlier 



THE CRYSTALLINE LENS. 399 

or later, and is a very serious event ; for in the vast majority 
of cases, do the surgeon what he may, it leads to loss of the 
eye. Its onset is made known by severe pain of a continuous 
aching kind in and about the eye ; and is thus easily dis- 
tinguished from the slight, short, stabbing pain, with long in- 
termissions, which some patients complain of, and which has 
no evil import. On removing the bandage the eye will be 
found full of tears, and the wound covered with a layer of 
mucopus, which can be removed with the forceps in one 
mass, while the aqueous humor and cornea may already pre- 
sent some opacity. In some hours more the corneal opacity 
increases considerably, the iris becomes distinctly inflamed, 
and the pupil filled with a mass of inflammatory exudation. 
The inflammatory process may remain confined to 
the wound and iris, and when, in the course of some 
weeks, it entirely subsides, it leaves the pupil drawn 
up toward the wound, so that an appearance as in 
figure 116 is presented ; or the inflammation may 
strike into the ciliary body and choroid, and produce purulent 
panophthalmitis, with total destruction of the eye. 

To combat siippuration the best method is the immediate 
cauterization of the corneal wound in its whole extent with 
the galvano-cautery. Also, the wound may be opened up 
from end to end with a spatula, the aqueous humor evacuated, 
and the anterior chamber washed out with injections of cor- 
rosive sublimate solution, while the conjunctival sac is irri- 
gated with the same solution. If necessary, these measures 
are to be repeated at intervals of eight or ten hours. Subcon- 
junctival or intraocular injections of corrosive sublimate may 
also be tried (see p. 177). 

Iritis. — Apart from the iritis which occurs in connection 
with suppuration of the wound, this complication is most 
usually due to irritation from masses of cortical lens substance 
left behind, or to infection during the operation, which can 




400 DISEASES OF THE EYE. 

show itself in this way rather than by suppuration. Iritis does 
not usually come on for some days after the operation. It is 
ushered in with the usual symptoms of pain, and is generally 
of the plastic variety. If it extend to the ciliary body, sympa- 
thetic ophthalmitis may result. Its treatment consists in 
strict confinement to a dark room, atropin, warm fomentations, 
leeching, and, internally, sahcylate of soda is most useful. 
In^these cases vision is liable to be damaged by pupillary exu- 
dation, which remains as a permanent obstruction to vision. 

Cystoid Cicatrix. — After convalescence, all the foregoing 
dangers having been escaped, the cicatrix in the corneal 
margin sometimes bulges and becomes semi-transparent, pre- 
senting the appearance of a vesicle, and may attain a large 
size. The extremities of the late incision are the most common 
positions for this condition, but it may occupy the entire length 
of the cicatrix. It does not generally come on for some weeks 
or more after the operation. In some cases it is caused by a 
tag of iris which is incarcerated in the wound ; but in other 
cases probably by a bit of capsule, which has similarly healed 
in the wound. Irregularity in curvature of the cornea and 
consequent irregular astigmatism are the least of its evil con- 
sequences. If the condition be caused by incarceration of 
iris, the pupil will be gradually drawn close to the upper 
corneosclerotic margin ; while, if it be caused by a portion of 
capsule, iridocyclitis may be produced. Whether the iris or 
the capsule be the cause, these eyes are always exposed to the 
danger of a sudden onset of purulent iridochoroiditis (see 
p. 306). All this demonstrates the immense importance of 
attention to those details of the operation which are calculated 
to obviate incarceration of iris, or of capsule, in the cicatrix. 

Cataract Extraction without Iridectomy.* — This 



* Known very generally now as the simple method, while the operation com- 
bined with an iridectomy is commonly termed the combined method. 



THE CRYSTALLINE LENS. 401 

method is older than the Hnear, von Graefe's, or the three 
milHmeter flap-operation, and used to be known as the flap- 
operation. It has been revived within recent years by some 
distinguished ophthalmic surgeons, chiefly in Paris, but also 
in Germany, America, and in England. It differs from the 
three millimeter flap-operation in that the incision occupies 
a greater extent (about one-third) of the circumference of the 
cornea, and that no iridectomy is made. Formerly the knife 
used was triangular in shape (Beer's knife), but von Graefe's 
cataract knife is the instrument now employed. The round 
pupil, and consequent somewhat prettier appearance of the 
eye, is the one advantage which can be claimed for this pro- 
cedure over the three millimeter flap-operation, as it has 
been above described ; for the vision with a circular pupil is 
not better than where a small iridectomy has been done. As 
a set-off against the circular pupil, the extraction without iri- 
dectomy exposes the eye to the serious danger of prolapse of 
the iris into the wound. These operators make it a rule to 
perform an iridectomy in all cases where they cannot satisfac- 
torily repose the iris after deliver}^ of the lens ; but even where 
they can repose it well they are not, they state, secure against 
the occurrence of a prolapse within the first two or three days 
after the operation ; nor do the}' find that eserin, or any other 
means, provides the desired safeguard. It is admitted that 
prolapse of the iris takes place after a number of these opera- 
tions'^, and that there is no means of foretelling in what eyes 
it will occur. The prolapsed portion of iris heals in the 
wound, which then, in a few weeks, becomes more or less cys- 
toid and bulging, causing displacement of the pupil and 
irregular curvature of the cornea, with resulting deterioration 

*Even Knapp, who has had very good results, admits from 6 to 12 per cent, of 
prolapses. He now lets the patient go to bed without a bandage, and if no pro- 
lapse occurs in from five to thirty minutes he applies one. Should a prolapse 
appear it is abscised. 
34 



402 DISEASES OF THE EYE. 

of vision. Nor is this all ; for such eyes are liable — weeks, 
months, or even years after the operation — to take on severe 
iridocyclitis, ending in total loss of sight. Another disadvan- 
tage of this operation is that removal of cortical remains cannot 
be so effectually performed as where a coloboma has been 
made. 

Therefore, while admitting the charm of a circular pupil, I 
am of opinion that the question is not <vhether the appearance 
of some of the eyes operated on is pleasing to us and to others 
who inspect them, but rather what advantage the greatest 
number of persons operated on derive from the operation. 
With sentimental talk about " mutilation " of the iris I cannot 
pretend to sympathize. If the advocates of the method 
under discussion should ftnd a means of insuring the eye 
against prolapse of the iris, the operation will be placed upon 
a different footing ; but until then the procedure cannot be 
recommended. 

It is easy to understand why, in the simple extraction, pro- 
lapse of the iris with subsequent incarceration is so liable to 
occur, even some days after the operation, and why it is so 
difficult to devise a sure means for preventing the accident ; as, 
also, how it is that even a very narrow coloboma is sufficient 
to protect the eye from this disaster. And yet I am inclined 
to think that among those oculists who have reverted to the 
simple method there are some who do not realize the modus 
operandi in either case. Within a few hours after the opera- 
tion the wound in the corneal margin most commonly closes, 
the aqueous humor collects, and the anterior chamber is re- 
stored. But it takes many hours more for the delicate union 
of the lips of the wound to become quite consolidated, and 
during this time it requires but little — a cough, a sneeze, a 
motion of the head, the necessary efforts in the use of a urinal 
or bedpan, no matter how careful the nursing — to rupture the 
newly-formed union ; and, as a matter of fact, this often does 



THE CRYSTALLINE LENS. 403 

take place. The aqueous humor then flows away through the 
wound with a sudden gush, and, where the simple extraction 
has been employed, carries with it the iris. Doubtless, in this 
event, it is that portion of the aqueous humor which is situ- 
ated behind the iris which is chiefly concerned in the iris- 
prolapse ; the aqueous humor in the anterior part of the ante- 
rior chamber probably flows off without influencing the posi- 
tion of the iris. The advocates of the simple operation en- 
deavor to prevent secondary iris-prolapse by a spastic contrac- 
tion of the pupil, produced by eserin, which is instilled at the 
conclusion of the operation, and, again, by some operators, a 
few hours afterward. In most instances the desired end is by 
this means effected. But there is a considerable percentage 
of the cases in which the contraction of the sphincter iridis is 
overcome by the pressure of the aqueous humor from behind, 
and iris-prolapse takes place. 

How, then, does the formation of a coloboma prevent pro- 
lapse of the iris when the wound bursts, as I have described ? 
Not because the portion of iris which is liable to prolapse 
has been taken away. That would mean nothing less than 
the whole of that part of the iris which corresponds to the 
length of the opening in the corneal margin. But the colo- 
boma averts secondary iris-prolapse, because it provides a 
gateway, a sluice, for the aqueous humor contained in the 
posterior part of the anterior chamber to escape directly 
through the wound, without carrying with it the iris in its 
rush ; and it is evident that the narrowest coloboma which 
can be formed will be amply sufficient for the purpose. To 
my mind a narrow iridectomy here is no "mutilation of the 
iris," but rather a measure which rests upon a sound scientific 
basis, and which is calculated to insure the safety of the eye 
in an important particular. 

In 354 consecutive extractions I have had four iris-prolapses 



404 DISEASES OF THE EYE. 

with incarceration, as compared with 6 to 12 per cent, of iris- 
prolapses which the best statistics of operators by the simple 
method now show. 

As to disfigurement of the eye, there is practically none 
when the coloboma is so narrow and is situated in the upper 
part of the iris. The pupil, too, is movable, almost, if not 
quite, as much so, I venture to say, as in most cases of simple 
extraction. For it is entirely a mistake to suppose that a 
narrow coloboma renders the pupil immovable. Where there 
are no adhesions between the pupillary margin and the capsule, 
as frequently happens, the reaction to light is active ; a drop of 
atropin will dilate the pupil widely, and a drop of eserin will 
contract it. 

Mental Derangements after Cataract Extractions. — After 
cataract extractions, during the period of confinement to bed, 
passing mental disturbances are sometimes seen in old people. 
This usually takes the form of confusion of ideas, hallucina- 
tions, and terror. It is hard to assign a cause for it, but 
probably it is mainly due to the quiet and the exclusion of 
light following on a period of some anxiety and excitement. 

A few doses of sulphonal, and permission to sit up, at least 
in bed, with the admission of more daylight, will be the best 
measures to adopt in such a case, and speedy restoration of 
mental equilibrium may be looked for with confidence. Care 
should be taken not to mistake the symptoms of atropin 
poisoning for this form of mental disturbance. 

Secondary glaucoma after cataract extraction occurs now and 
then, by whatever method the extraction may have been per- 
formed. This is contrary to what one would have expected, 
in view of the diminished contents of the globe, by reason of 
absence of the lens, and especially in those cases where an 
iridectomy has been made. High tension in these instances 
may come on soon after recovery from the cataract operation, 



THE CRYSTALLINE LENS. 405 

or after a good result has existed for many years. Treacher 
Collins'* and Xatanson's f microscopic investigations 
show that in these cases either the iris, the capsule, 
or the hyaloid has become entangled in the wound, 
and it seems that this leads in some cases to closure 
of the filtration angle in its entire circumference ; but, 
obviously, further information is required on this 
rather obscure question. 

A wide iridectomy, or a sclerotomy, should be 
made as soon as possible after the high tension shows 
itself, and by this means many of these eyes may be 
saved. Simple division of the capsule has produced 
a good effect in some cases. 

Discission or dilaceration means the tearing of 
the anterior capsule of the lens with a needle, so as 
to give the aqueous humor access to the lenticular 
fibers, which causes them to swell, and gradually to 
become soft, and then to be absorbed. The larger 
the capsular opening, the more freely is the aqueous 
brought in contact with the lens, and the more rapid 
is its swelling. The rapidity of the swelling and 
absorption depend, also, on the consistence of the 
lens. The softer it is, the more rapid is the process, 
the completion of which may require from a few 
weeks to many months. It is wise to make the first 
discission of moderate dimensions, in order to test 
the irritability of the e}'e, especially in adults. 

The instruments required are a spring speculum, 
a fixation forceps, and a Bowman's stop-needle (Fig. 
117). The pupil is to be dilated with atropin. 

The eye having been cocainized, the speculum applied, and 

* Tratis. Ophth. Soc, Vol. x, p. 108. 

f " Ueber Glaucom in aphakischen Augen," Dorpat, 1889. 



4o6 



DISEASES OF THE EYE. 



the eye fixed close to the inner margin of the cornea, the 
needle is passed perpendicularly through the cornea in its 
lower and outer quadrant, at a point corresponding to the 
margin of the dilated pupil. It is then advanced upward to 
the upper margin of the pupil (Fig. Ii8), where it is passed 
into the capsule, but not deeply into the lens, and a vertical 
incision is effected by withdrawing the instrument slightly. 
If an extensive opening in the capsule be wished for, a hori- 
zontal incision can be added to the vertical by a corresponding 
motion of the needle. During these manoeuvers the cornea, 

at the point of puncture, 
must form the fulcrum for 
the motions of the instru- 
ment. The instrument is 
then withdrawn, and some 
aqueous humor escapes 
through the opening. Atro- 
pin is instilled, and the ban- 
dage applied. The patient 
is kept in bed for a day, 
and then the bandage may 
be dispensed with, and dark spectacles worn. The iris is 
to be kept well under the influence of atropin until the absorp- 
tion of the lens is completed. Repetition of the operation is 
called for if the opening be so small as to admit of but a very 
slow absorption of the lens, or if, as sometimes happens, the 
opening should become closed up. 

This method is applicable to all complete cataracts up to 
the twenty-fifth year of age, and to those lamellar cataracts in 
which the opacity approaches so close to the periphery of the 
lens that nothing can be gained by an iridectomy. After the 
above age the increasing hardness of the nucleus, and the 
increasing irritability of the iris, render the method unsuit- 
able. 




Fig. ii8. 



THE CRYSTALLINE LENS. 407 

Discission is a safe procedure when used with the above in- 
dications and precautions. The danger chiefly to be feared is 
iritis, from pressure on the iris of *the swelhng lens masses. 
When this occurs, or is threatened, removal of the cataract 
by a linear incision in the cornea should be at once performed. 
A safeguard against iritis may be had in a preliminary iridec- 
tomy (von Graefe), and it is perhaps well to do this in all cases 
over fifteen years of age, the discission following some weeks 
afterward. 

Another danger consists in glaucomatous increase of ten- 
sion (secondary glaucoma), which may come on without any 
subjective symptoms, while the absorption of the lens runs its 
proper course. It may happen, in this way, that, when ab- 
sorption of the cataract is completed, the eye will be found 
blind from glaucoma. Frequent testings of the tension of the 
eye during the cure are, therefore, a most important precaution. 
Should the tension rise, removal of the lens through a linear 
incision in the cornea is at once indicated, or the suction op- 
eration may be employed. 

Suction' Operation of Cataract. — This method can only 
be used for semi-fluid or soft cataracts. 

The pupil having been well dilated with atropin, and the 
eye cocainized, a free opening is made in the capsule of the 
lens with a discission-needle. A linear incision is then made 
in the cornea about half-way between its center and its mar- 
gin, and the point of a Bowman's or a Teale's syringe intro- 
duced through it, and through the opening in the capsule, 
into the substance of the lens. Gentle suction is then applied, 
and the lens substance drawn into the syringe. The syringe 
should not be passed behind the iris. If it be thought that 
the cataract is not sufficiently soft, it is desirable to allow some 
time (a fortnight or so) to elapse between the discission and 
the suction, in order that the lens substance may undergo dis- 
integration by the action of the aqueous humor. 



4o8 DISEASES OF THE EYE. 

Secondary Cataract and its Operation — Capsulotomy. 

— The term secondary cataract, as here used (compare p. 375), 
usually means a closure of the opening in the anterior capsule 
left after the removal of a cataractous lens, with sometimes a 
thickening of the capsule, by which an impediment is offered 
to the rays of light in passing through the pupil. The thick- 
ening may have preexisted in the capsule, or it may be due 
to subsequent proliferation of the epithelial cells on the inner 
surface of the capsule. The term is also used with reference 
to those cases in which no central opening has been made in 
the capsule (peripheral capsulotomy), and where the latter 
causes imperfect vision. It is also used in those cases where, 
after cataract extraction, an exudation in the pupil, consequent 
upon iritis, has occurred. Finally, and most incorrectly, it 
is applied to the cases which figure 116 represents, in which, 
after suppuration of the wound with iridocyclitis, the iris is 
dragged upw^ard, and the pupil consequently obliterated. 

The most simple form of secondary cataract occurs as a 
very fine cobweb-like membrane, extending over the whole area 
of the pupil, which can often only be discovered by careful 
examination with oblique illumination. It may not appear 
until some months after the extraction, and then causes the 
patient to complain of diminished acuteness of vision. It is 
a simple matter to make a rent in this delicate membrane with 
a discission-needle. 

Where there are thick opacities in the capsule, or inflamma- 
tory exudation into the pupil, with, probably, adhesions of the 
iris to the pupillary membrane, extraction of the latter has 
been proposed and practised, but is associated with so much 
danger, from the unavoidable dragging on the ciliary body and 
iris, that the proceeding is not often employed. 

Sir W. Boivmaii s method with two needles is here much 
preferable. In it the point of a discission-needle is passed 
through the inner quadrant of the cornea, and into the center 



THE CRYSTALLINE LENS. 



409 



of the opacity (Fig. 119), and then, with the other hand, a 
second needle is passed through the outer quadrant of the 
cornea, and into the membrane, close beside the first needle. 
The points of the needles are now separated from each other 
by approximation of their handles, and in this way a hole is 
made in the membrane. A very small opening in the capsule, 
if quite clear, is sufficient to establish good vision. 

Dr. Noyes' MetJiod^ — A Graefe's cataract knife is entered 
in the horizontal meridian of the cornea at its temporal mar- 
gin, and a counterpuncture made in the same meridian at the 




inner corneal margin. The point of the knife is now withdrawn 
into the anterior chamber, and made to puncture the second- 
ary cataract, and is then removed from the eye. Two blunt- 
pointed hooks are then entered into the anterior chamber, one 
through each corneal puncture, and the point of each passed 
through the opening in the membrane made with the knife. 
By traction on the hooks this opening is enlarged, without 
any dragging on the iris or ciliary body. 

*" Diseases of the Eye," London, 1882, p. 251. 



4IO DISEASES OF THE EYE. 

Iridotomy. — For the cases, as in figure Ii6, where the iris 
forms a complete and tightly stretched curtain across the 
pupil, iridectomy is the operation which readily suggests itself. 
In very few cases, however, does it give a satisfactory result, 
owing to the inflammatory products which lie behind the iris, 
and which close up any artificial pupil by their proliferation, 
which is set going by the dragging of the iris with the forceps. 
Repeated iridectomies may finally produce a clear pupil, but 
iridotomy, in which there is no dragging of the iris, is a better 
operation in these cases. 

There are several modes of performing iridotomy, that of 
de Wecker being the best. A vertical incision having been 
made in the cornea, about three mm. long, and the same distance 
removed from its inner margin, the closed blades, one of 
which has a sharp point, of de Wecker' s forceps-scissors are 
passed into the anterior chamber. The blades are then 
opened, and the sharp point of one of them is forced through 
the stretched iris, and some three or four mm. behind it. By 
now closing the blades the tightened iris-fibers are cut across, 
and on their retraction a central clear pupil is formed in the 
iris and retroiridic tissue. 

Dislocation of the Crystalline Lens. — This may be con- 
genital, and due to arrested development of the zonula of 
Zinn ; or it may be the result of disease, such, for example, 
as anterior sclerochoroiditis ; or it may be caused by a blow 
or other trauma. 

The dislocation may be partial or complete. In the former 
case it is often so slight as to be discoverable only when the 
pupil is widely dilated, the margin of the lens becoming then 
visible as a curved black line, in some one direction, by aid of 
the ophthalmoscope mirror ; or the displacement may be so 
great as to bring the margin of the lens across the center of 
the undilated pupil, in which case one part of the eye will be 
highly hypermetropic, while in another part it will be myopic. 



THE CRYSTALLINE LENS. 411 

Complete dislocation may take place into the anterior chamber, 
into the vitreous humor, and even under the conjunctiva, if 
the sclerotic has been ruptured. 

The symptoms in partial dislocation are those of loss of 
power of accommodation, and monocular double vision. Irido- 
donesis — /. c., trembling of the iris when the eye moves — is pre- 
sent, as a rule, in consequence of the loss of support provided 
by the lens. In complete dislocation the symptoms are those 
of aphakia — /. e., extreme hypermetropia, and want of power 
of accom.modation. 

Treatment. — In partial dislocation it is rarely that any treat- 
ment can be of service. The prescribing of spectacles suited, 
so far as it is practicable, to the faulty refraction is indicated. 
In complete dislocation of the lens into the anterior chamber 
its extraction is usually required, especially if it causes symp- 
toms of irritation. Dislocation into the vitreous humor is 
generally unattended by irritation ; but when the latter does 
arise, removal of the lens by aid of a spoon, through a per- 
ipheral corneal incision, has to be attempted. 

Lenticonus is a very rare congenital anomaly of the lens, 
in which its anterior surface, or, still more rarely, its posterior 
surface, is cone-shaped. 

Aphakia {ft.^ priv. ; (paxaq^ a lentil, lens), or Absence of the 
Crystalline Lens.-^The condition of the emmetropic eye 
after the removal of a cataract is one of high hypermetropia, 
and the power of accommodation is wanting. Consequently, 
in order that the eye may have the best possible sight for dis- 
tant objects, a high convex glass has to be experimentally 
found to suit it, and stronger lenses must be prescribed for 
shorter distances. 

The degree of vision obtained varies considerably in differ- 
ent cases ; frequently V = |- is obtained, but V = -f-^ may be 
regarded as a satisfactory result ; and even lower degrees, 
which enable the patients to find their way about with com- 



412 DISEASES OF THE EYE. 

fort, are classed as successful operations. The vision often 
improves for some months after the operation, patients who 
at first had only y^-g- or so advancing up to -| or |-. For read- 
ing, writing, etc., at about 25 cm., a still higher convex glass 
must be provided. If the correcting lens for distant vision 
be -f 10 D, its power, for vision at 25 cm., must be increased 
by the lens which would represent the amplitude of accom- 
modation from infinite distance up to 25 cm. This lens is 
four D (because yy^ = 4) ; therefore + 14 D is the lens 
required. With these two lenses most patients are satisfied. 
For distinct vision at middle distances they learn to vary the 
power of the lenses by moving them a little closer to, or 
further from, the eye ; but if necessary a lens can be pre- 
scribed for distinct vision at any desired distance. 

In the case of hospital patients, one is often obliged to se- 
lect the -|- glasses in a fortnight or three weeks after the 
operation, but the result is more satisfactory when the selec- 
tion can be postponed for six weeks or two months. Perma- 
nent wearing of the -f glasses should not be permitted until 
all redness of the eye has passed off, and this varies in differ- 
ent cases. Until then, also, dark protection-spectacles should 
be worn. 

In the majority of cases, after cataract operations, the best 
vision is not obtained until a certain degree of astigmatism is 
corrected. It is caused by a flattening of the vertical merid- 
ian of the cornea, due to the incision at its upper margin, and 
hence is against the rule (see p. 56). An obliquity in the in- 
cision often produces an obliquity in the principal meridians 
of the astigmatism. The degree of astigmatism varies, and 
may be very high. Out of 48 cases studied by Jackson * 
only 1 1 had less than two D of astigmatism. It rapidly 
reaches its maximum after the operation, and then gradually 

* Ophthalmic Revie7v, December, 1893, p. 349. 



THE CRYSTALLINE LENS. 413 

diminishes for weeks or months, and in some cases completely 
disappears ; hence glasses for permanent use should not be 
prescribed for at least a month or two subsequent to the 
operation. 

For an account of erythropsia after cataract extraction see 
chapter xvii. 



CHAPTER XIV. 

DISEASES OF THE VITREOUS HUMOR. 

Purulent inflammation of the vitreous humor, to which, 
unfortunately, the name pseudogHoma is sometimes appHed, 
occurs only as the result of perforating injuries, or of the lodg- 
ment of a foreign body, or as an extension of a purulent process 
from the choroid (p. 306). 

Oplitlialinoscopically , a purulent deposit in the vitreous humor 
gives a yellowish reflection. It is to be distinguished from a 
somewhat similar appearance in glioma of the retina by the 
history, by its early complication with more or less severe 
iritis, by the very frequent retraction of the periphery of the 
iris, with bulging forward of its pupillary part, and by the 
diminished tension of the eye, while a lobulated appearance is 
not so usual in it as in glioma. Again, in glioma the vitreous 
humor remains clear, while in this disease it is hazy. 

The condition, if at first confined to the vitreous humor, soon 
extends to the surrounding tissues, and usually leads to pan- 
ophthalmitis and complete destruction of the eye. 

Inflammatory affections of the vitreous humor, other 
than the purulent form, are for the most part the consequence 
of diseases of the choroid, ciliary body, or retina, and display 
themselves as opacities of various kinds. These are either cells 
derived from the primarily diseased tissue, or they are second- 
ary changes (connective-tissue development), the result of this 
cellular invasion. 

The chief varieties of vitreous Jutvior opaeities are : (i) The 
dust-like opacity so characteristic of syphilitic disease of the 

414 



THE VITREOUS HUMOR. 415 

retina and choroid. It may occupy the entire vitreous humor, 
but is frequently confined to the region of the ciliary body, 
or to that of the posterior layers of the vitreous humors. 
(2) Flakes and threads. These occur with chronic affections 
of the choroid or ciliary body, and may be the result also of 
hemorrhages into the vitreous humor. They invade every 
portion of the humor. (3) Membranous opacities, which are 
rare, and are probably the result either of extensive hemor- 
rhagic extravasations or of choroid exudations. 

Hemoi'vhages into the vitreous humor are not uncommon, 
and are the result of certain diseases of the retina and choroid, 
w^hich are accompanied by hemorrhages in those membranes. 
They are common in old people, but very large hemorrhages 
also occur in young adults (see Apoplexy of the Retina). They 
are also caused by blows on the eye, which rupture the 
choroid or retinal vessels. Most of the alterations occurring 
in the vitreous humor are attended with, or give rise to, fluidity 
of it, and may lead to detachment of the retina. 

TJie diagnosis of opacities in the vitreous humor is made 
with the ophthalmoscope mirror and a not very bright light, or 
with the plane mirror. If a very bright light and a concave 
mirror be employed, the finer opacities will not be readily 
seen. The pupil being illuminated, the patient is directed to 
look rapidly in different directions, when the opacities will be 
seen to float across the area of the pupil, as they are thrown 
from one side of the e}'e to the other. 

Opacities in the vitreous can be distinguished from those in 
the lens by the fact that the latter are fixed, and are arranged 
mostly in a radiating manner. Opacities which lie behind the 
center of curvature of the cornea, as examined with the 
ophthalmoscope mirror, seem to move in the opposite direc- 
tion when the patient moves his eye ; while those which lie in 
front of that point move in the same direction as the eye. 
Therefore, opacities in the lens and anterior part of the vitreous 



4i6 DISEASES OF THE EYE. 

humor, about 0.6 mm. behind the lens,* will move in the 
same direction. 

Another and very fine method for the detection of delicate 
opacities in the vitreous is by placing a high -f lens, say -|- 
10 D, behind the ophthalmoscope mirror, and then going 
close to the eye, as in the examination of the upright image. 
Minute opacities will then be seen as black dots floating in the 
vitreous humor. 

When the vitreous humor is full of blood, no red reflex can 
be obtained with the ophthalmoscope, and the pupil looks 
quite black. By focal illumination we can observe, in this case, 
that the lens is perfectly clear, and sometimes the red color 
of the extravasated blood can be seen behind it. 

The ophthalmoscope does not always detect changes in the 
choroid or retina when there are opacities in the vitreous ; and 
in many such cases we are led to the belief that the diseased 
changes in the choroid or retina are too fine to be seen with 
the ophthalmoscope, or that they are situated in the region of 
the ciliary body which is out of view. 

Vision is affected by opacities in the vitreous humor in pro- 
portion to their density, and to the extent to which the vitreous 
humor is occupied by them. The patients often observe them 
as floating positive scotomata in their field of vision. These 
entoptic appearances are caused by the shadows of the opacities 
thrown on the retina. 

The prognosis depends on the cause of the opacities. Small 
hemorrhagic extravasations in young people are readily ab- 
sorbed. The dust-like opacity of specific retinitis is also favor- 
able for absorption, while extensive hemorrhages in older 
people, and the flake and thread opacities, frequently remain 
as permanent obstructions. Moreover, by shrinking, many of 

* Radius of curvature of cornea, 7.829 mm. Distance from anterior surface of 
cornea to posterior surface of lens, 7.2 mm. (Landolt and Wecker, IVaite, T., iii, 
P-II3.) 



THE VITREOUS HUMOR. 417 

the more organized opacities give rise to detachment of the 
retina from the choroid, and consequent bhndness. 

Treatment consists, above all, in that for the exciting cause. 
Besides this, Heurteloup's artificial leech, or dry cupping on the 
temple, is most useful ; and in many cases, soon after the 
application, a marked clearing up of the vitreous is apparent. 
Pilocarpin hypodermically is worthy of trial. In one case 
von Graefe operated on membranous opacities by tearing them 
with a needle, and with a successful result. 

Mouches volantes, muscse volitantes, and myiodeopsia 
{jwia, a fly ; o^'tq, seeing) are terms applied to the motes which 
people frequently see floating before their eyes, but which do 
not interfere with the acuteness of vision, nor can the ophthal- 
moscope detect opacities in the vitreous humor, or any other 
intraocular disease. These motes are most apparent when a 
bright surface, such as a white wall or the field of a micro- 
scope, is looked at. Mouches volantes have no clinical im- 
portance. Those annoyed with them should be strongly 
recommended not to look for them, as in that case others are 
very apt to become visible. They depend, probably, upon 
minute remains of the embryonic tissue in the vitreous humor. 

Fluidity of the vitreous humor, or synchysis {<yw, to- 
getlier ; x^^^ ^^ poitr), is not rare. It can only be diagnosed 
with certainty when the humor contains floating opacities. 
Lov/ tension of the eyeball does not always indicate fluidity of 
the vitreous, although soft eyeballs nearly always contain fluid 
vitreous humor. Trembling of the iris is also no sign of fluid 
vitreous, but merely indicates that the iris is not supported in 
the normal way by the crystalline lens. Defective zonula of 
Zinn, however, is often caused by, or is a concomitant of, fluid 
vitreous, and, by causing displacement of the lens, would allow 
of trembling of the iris. TJie causes of synchysis are choroid- 
itis and staphyloma of the choroid and sclerotic, and it also 
occurs as a senile change. 
35 



4i8 DISEASES OF THE EYE. 

Synchysis scintillans is a fluid condition of the vitreous 
humor, with cholesterin and tyrosin crystals held in suspen- 
sion in it. The ophthalmoscopic appearances are very beauti- 
ful, resembling a shower of golden rain. A satisfactory 
explanation for the occurrence of these crystals in this position 
has not yet been given. They usually occur in old people, 
and seldom cause any marked deterioration of vision. 

Fluidity of the vitreous humor is not, per sc, a condition of 
serious import, unless the eye come to be the subject of an 
operation, involving an incision in the corneosclerotic coat, 
when it renders prolapse of the vitreous more liable to take 
place. 

Foreign Bodies in the Vitreous Humor. — One of the 
most common accidents to the eye is perforation of the 
sclerotic, or of the cornea and crystalline lens, by a small 
foreign body (shot, morsel of iron, copper, stone, or glass), 
which then lodges in the vitreous humor. 

In cases where the ophthalmoscope fails us, owing to 
extravasation of blood, etc., it is sometimes not easy to say 
whether the foreign body be in the eye, or whether it may 
merely have punctured the sclerotic without passing through 
it, and then fallen to the ground. If it be known to have 
been a small foreign body, which has flown against the eye 
with force, the probabilities are that it is lodged in the eye. 

But if the case be brought immediately, or soon after the 
accident, and there be no intraocular hemorrhage to obscure 
our view, the foreign body may frequently be detected with 
the ophthalmoscope in the vitreous humor as a dark or glitter- 
ing body, according to its nature, and focal illumination, with 
dilated pupil, will often help us to discover a foreign body 
situated in the anterior part of the vitreous humor. Or, if it 
cannot be seen, an opaque streak through the vitreous humor, 
one end of which corresponds with the sclerotic wound, may 
indicate the track taken by a foreign bod\-. 



THE VITREOUS HUMOR. 419 

In case the foreign body has perforated the cornea and 
reaches the vitreous humor through the circumlental space, a 
counter-opening will be found in the iris ; while, if it be 
supposed to have passed through the cornea and lens, the 
openings, both in the anterior and posterior capsule of the 
lens, should be sought for. 

It is rarely that a foreign body, whether it remains free, or, 
as sometimes happens, becomes encapsuled, is tolerated per- 
manently in any part of the interior of the eye, and the event 
should never be calculated on in the treatment of such a case. 

As a rule, foreign bodies in the vitreous, as elsewhere within 
the eye, soon produce violent inflammatory reaction. This 
occurs either by reason of infective microorganisms being 
introduced into the eye with the foreign body, or it may be 
caused by the oxidization of the foreign body, when, as is 
most common, it is of iron or copper. The form of inflam- 
mation may be either a plastic or purulent uveitis, in the latter 
case with purulent infiltration of the vitreous humor and 
hypopyon. 

An eye which contains a foreign body that is not, or cannot 
be, at once removed, may be regarded as lost ; and such an 
eye becomes, moreover, one of the surest sources of sym- 
pathetic ophthalmitis. 

It is, consequently, of the utmost importance to remove 
every foreign body from the interior of the eye if possible, 
and with the least delay ; or, if not, carefully to watch the eye, 
and at any sign of inflammatory reaction to remove the eye- 
ball. Indeed, in view of the fact that this inflammatory 
reaction almost invariably comes on sooner or later, I should 
be inclined to remove most of these eyes at once when the 
foreign body cannot be extracted. 

Removal of tJie foreign body is very often an extremely diffi- 
cult and disappointing undertaking, but it should always be 
attempted when, being neither steel nor iron, it is visible within 



420 DISEASES OF THE EYE. 

the eye, so that its position can be determined with the oph- 
thalmoscope or by focal illumination. The introduction of the 
magnet for the removal of fragments of the two metals named 
has made it unnecessary that they should in every case be vis- 
ible, although here, too, the chances of success are much en- 
hanced if the foreign body can be accurately localized. In 
all these operations it is necessary that the patient should be 
deeply under the influence of an anesthetic, in order that as 
little vitreous humor as possible may be lost. And, again, 
strict aseptic measures must be observed, lest by our operation 
the very form of mischief be produced which it is our desire to 
avert. 

There are several methods of proceeding. Atoms of glass, 
copper, stone, etc., may sometimes be removed through an 
incision in the sclerotic which is either an enlargement of the 
opening made by the foreign body, or is a special one at a 
point more nearly corresponding to the actual position of the 
latter in the eye. This incision should lie between two recti 
muscles, should have an antero-posterior direction, and, in 
order that it may gape but little, should be a puncture with a 
broad keratome. Prolapse of the vitreous is then produced by 
pressure on the eyeball, and the foreign body is evacuated. 

This method should only be tried when the foreign body 
is situated in the periphery of the vitreous, and toward the 
equator of the eye, where the opening for its exit can be made 
in its immediate neighborhood ; but the proceeding is often 
attended with disappointment, much vitreous being lost, while 
the foreign body remains in the eye. 

Or a forceps is passed in through the opening, and while 
the foreign body is kept in view with the ophthamoscope, it is 
seized and drawn out. This plan is also unsatisfactory, as, 
loss of vitreous occurring, the cornea becomes flaccid, and the 
view of the foreign body is soon obscured. 

Again, some surgeons prefer to make tlieir opening not close 



THE VITREOUS HUMOR. 421 

to the foreign body, but exactly at the opposite side of the 
eyeball, by which means they can often reach the foreign body 
with greater ease, and with less injury to the tissues. 

The magnet, thanks to M'Keown, of Belfast,* has of late 
years come into use for the removal of fragments of steel and 
iron from the interior of the eye, and especially from the vitre- 
ous humor. Electro-magnets are those now employed for this 
purpose, the instruments of Hirschberg f and of Simeon Snell J 
being the most suitable. Figure 120 represents Snell's instru- 
ment in two-thirds its actual size. It is a core of soft iron, 
around which is placed a coil of insulated copper wire, the 
whole inclosed in an ebonite case. To one end of the instru- 
ment are attached the screws to receive the battery connections. 




Fig. 120. 

At the other extremity the core projects just beyond the ebo- 
nite jacket, and is tapped, and into it screws the needle. 
Needles of various kinds or shapes can be adjusted to the 
magnet according to the case to be dealt with. The battery 
used is a quart bichromate element. A needle being passed 
through the sclerotic opening, is advanced toward the foreign 
body, when the latter adheres to it and is drawn toward the 
wound. Much care is required in drawing it through the 
opening, lest it be rubbed off the needle in its passage. A 

* Brit. Med. Journal, 1874, Vol. i, p. 800, and elsewhere. 
I Centralblatt fi'ir prak. Augenheilkunde, 1879, p. 380. 
\ " The Electro-magnet," etc., London, 1883. 



422 DISEASES OF THE EYE. 

forceps is generally used at this part of the proceeding, either 
to dilate the wound, or to seize the foreign body and extract 
it. Haab "^ recommends the use of a very powerful rnagnet 
applied to the surface of the eyeball ; he has succeeded with it 
in removing bits of steel through the wounds inflicted by them. 

The magnet may also be used for determining the presence 
of a fragment of steel or iron in the vitreous, if on bringing it 
close to the eye motions are imparted to the fragment. T. R. 
Pooley t made some very elegant experiments to ascertain 
the presence of a piece of steel in the eye, upon the principle 
that if a fixed magnet attracts a movable piece of steel, a fixed 
piece of steel will attract a movable magnet. He magnetized a 
sewing-needle, and suspended it by a fiber of silk attached to 
its center, and, on bringing it near an eye which contained an 
atom of steel, the needle dipped toward the foreign body. 
Or, if he magnetized the foreign body by passing a galvanic 
current through the eye, the motion of the suspended magnet 
was even more decided. 

Cysticercus in the vitreous humor is not of rare occur- 
rence in some parts of Germany, but there have been only one 
or two such cases observed in the British Isles. J 

The original seat of the entozoon is usually beneath the 
retina (see Chap, xv), through which it breaks to reach the 
vitreous humor ; but it also sometimes makes its first appear- 
ance in the vitreous. It is recognized by its peculiar, some- 
what dumb-bell shape, its iridescence, and its peristaltic 
motions. The vitreous humor often becomes full of peculiar 
membranous opacities. 

Treatment. — Removal by operation. The prospects for the 

* Bericht d. Ophthal. Gesellschafi zu Heidelberg, I^g2. 

t Archives of Ophthalmology , l88o, p. 219. 

X Since the above was written, Dr. Hill Griffith has read a paper at the Oph- 
thal. Soc. U. K. , November 12, 1896, on seven cases of cysticercus in the vitreous 
humor which he had observed at Manchester. 



THE VITREOUS HUMOR. 423 

eye are very much worse than in the case of a subretinal 
cysticercus. 

Blood-vessels are sometimes formed in the vitreous 
humor ; they spring from the retinal vessels, of ten in con- 
nection with connective-tissue formations which accompany 
hemorrhages ; but sometimes small loops arise in the neigh- 
borhood of the disc, without any hemorrhagic disease. 

Persistent Hyaloid Artery. — In intrauterine life the 
hyaloid artery is a prolongation of the central artery of the 
retina, and runs from the papilla to the posterior surface of 
the crystalline lens. It completely disappears prior to birth, 
except in those rare cases where it remains as an opaque 
string, which may stretch the whole way from papilla to lens, 
or may extend only part of the way. It is then thrown into 
wave-like motions by the motions of the eyeball, and is easily 
recognized with the ophthalmoscope. It does not usually 
cause any disturbance of vision. 

Detachment of the vitreous humor from the retina, 
although probably a common diseased condition, cannot as 
yet be recognized with certainty during life, and rarely becomes 
the immediate cause of blindness. Its danger lies in its lia- 
bility to bring about detachment of the retina. 

Detachment of the vitreous may be either idiopathic or due 
to trauma." In the idiopathic cases chronic choroiditis is 
the primary disease, which gives rise to a change in the fine 
connective-tissue elements of the vitreous, with consequent 
shrinking of this body. Yet, with the ophthalmoscope, the 
choroid may seem normal ; and, moreover, although floating 
opacities may be present in the vitreous chamber, yet it is 
quite possible for a perfectly clear vitreous to be detached.* 

The condition occurs in connection with high degrees of 
myopia, where choroiditis is also common, and is probably 

* Nordenson, "Die Netzhautablosung," Wiesbaden, 1887. 



424 



DISEASES OF THE EYE. 



the most important factor in the production of the detachment 
of the retina, so frequent in these eyes. Anterior staphyloma, 
hemorrhages into the vitreous humor, and neoplastic growths 
between the vitreous and retina also give rise to detachment 
of the vitreous. 

Detachment of the anterior portion of the vitreous occurs 
in many cases of iridocyclitis. 

With regard to traumatic cases, all perforating injuries 
attended with loss of vitreous, including cataract operations — 
and sometimes, when the wound is in the sclerotic, with- 
out loss of vitreous — are 
liable to be followed by 
detachment of the vitre- 
ous. 

I have * recorded a 
case in which detach- 
ment of the vitreous was 
the chief lesion in the 
eye, and was the cause 
of blindness, the vision being reduced to perception of light. 
The detachment had probably been brought about by an 
idiopathic hemorrhage from the ciliary body into the anterior 
part of the vitreous. It lay (Fig. 121) immediately behind 
the lens and in contact with it, and presented the appearance 
of a grayish opacity, much like a detached retina but for the 
absence of retinal vessels. Suspicion of an intraocular tumor 
existing, the eye was removed. The vitreous lay against the 
ciliary body and lens, while the vitreous chamber was filled 
with serous fluid, and the retina was in its normal position. 
In the retina, toward the ora serrata, there were a few minute 
hemorrhages. 




Fig. 



* Trans. Ophihal. Soc, 1882, p. 41, 



CHAPTER XV. 

DISEASES OF THE RETINA. 

Diseases of the retina may, for the purpose of description, be 
conveniently grouped as follows : Alterations in Vascularity, 
Inflammation, Atrophy, Diseases of the Blood-vessels, Injury 
by Strong Light, Tumors, Parasitic Disease, Detachment, and 
lastly. Traumatic Affections. 

Alterations in the Vascularity of the Retina. 
Hyperemia and anemia of the retina, due to changes in 
the capillary vessels, cannot be seen with the ophthalmoscope, 
hence these terms are used to denote apparent enlargement or 
diminution of the principal branches of the central vessels. 
Venous engorgement may occur as a local condition, as in 
papillitis, retinitis, thrombosis of the central vein, or as part of 
general venous obstruction in cardiac and pulmonary diseases. 
Contraction of the arteries may also be due to local disease of 
the vessels — as embolism, albuminuric retinitis, etc. — and 
spasm (malaria, quinin), or, more rarely, to diminished blood 
supply from general causes (cholera). The opposite con- 
ditions, namely, diminution in the size of the veins, and 
enlargement of the arteries, are rarely noticeable. 

Inflammations of the Retina — Retinitis. 
Retinitis, in general, is characterized by the following oph- 
thalmoscopic appearances : diffuse cloudiness, especially of the 
central portion of the fundus, due to loss of transparency in 
the retina ; the optic papilla becomes more or less congested, 
36 ■ 425 



426 DISEASES OF THE EYE. 

with indistinctness of its outline, which in the erect image 
resolves itself into a delicate striation ; vascular engorgeinent, 
the retinal veins especially becoming enlarged and tortuous. 
The inflammation in some cases may subside at this stage, but 
as a rule JicmorrJiagcs and whitish exudations soon make their 
appearance. 

The various forms of retinitis are distinguished by the pre- 
dominance of some of the above signs, and also by the pecu- 
liar appearance and grouping of the exudations. 

If the optic papilla be not merely congested, but also swollen, 
the condition is called neuroretinitis. In some cases of retinitis 
the choroid is also involved, and to these the name choroido- 
retinitis is given. Inflammation of the retina is rarely a local 
affection, being in most cases due to general diseases, and 
hence it commonly occurs in both eyes. 

Syphilitic Retinitis (or Syphilitic Choroidoretinitis). — In- 
herited or acquired constitutional syphilis is liable to induce a 
form of chronic diffuse retinitis. In the acquired disease it is 
a later secondary symptom, coming on between the sixth and 
eighteenth month, often only in one eye. 

Witli the ophthalmoscope a slight opacity of the retina is seen 
extending from the papilla some distance into the retina, and 
very gradually disappearing toward the equator of the eye. 
The papilla is but slightly hyperemic, while its margins are 
indistinct, like those of the moon seen through a light cloud. 
The artery is not generally altered, and the vein but slightly 
distended. Opacities in the vitreous humor are not uncommon. 
They may be membranous or thread-like, but a diffuse dust- 
like opacity, filling the whole vitreous humor, is almost pathog- 
nomonic of a syphilitic taint, and may create much difficulty 
in the ophthalmoscopic diagnosis of the retinal affection. 

Disseminated choroid changes, in the form of small yel- 
lowish spots with pigmentary deposit, are very frequent, espe- 
cially toward the equator of the eye. Many observers, indeed, 



THE RETINA. 427 

hold that the whole process is primarily in the choroid, and 
that the retina is only secondarily affected. Fine whitish dots 
and pigmentary changes often occur about the macula lutea. 

Vision may be but slightly affected, but in the advanced 
stages it is usually much lowered. Central, or peripheral, or 
ring scotomata, or concentric defects of the field are found. 
The scotomata are often positive — /. r. , they can be seen by 
the patient as dark spots in the field. Night-blindness is a 
constant symptom, and the light-sense is enormously dimin- 
ished. The patients somtimes complain of sparks or lights, 
which seem to dance before their eyes, and occasionally also 
of a diminution in the size (micropsia) of objects, or of a dis- 
tortion (metamorphopsia) of their outlines. The micropsia is 
believed to be due to a separation from each other of the ele- 
ments of the layer of rods and cones b}^ subretinal exudation. 
The image of an object then comes into relation with fewer of 
these elements, and thence the mental impression is that of a 
smaller object than is conveyed by the image formed in the 
sound eye or on a sound part of the same retina. 

The progress of the disease is very slow, and is liable to re- 
lapses. In the late stages extensive pigmentary degeneration 
of the retina may come on, or disseminated choroiditis. But 
if the cases come under suitable treatment in an early stage, a 
cure may often be effected. 

Treatment. — The only remedy which is of real value is mer- 
cur}^, and that in an early stage. It should be used in a pro- 
tracted course of some weeks by inunction, combined at dis- 
cretion with small doses of calomel internally. Perchlorid 
of mercury hypodermically, in 2^ gr. doses once a day, is also 
a suitable measure. If mercurialization be effected it should 
not go further than a very slight stomatitis. Pilocarpin 
hypodermically, Turkish baths, and the artificial leech at 
the temple may be employed as adjuncts to the treatment. 



428 DISEASES OF THE EYE. 

When the mercurial course has been completed, iodid of 
potassium should be prescribed as an after-treatment. Com- 
plete rest of the eyes, and protection from strong light by 
dark glasses, are also necessary in this, as in many forms of 
retinitis. 

Hemorrhagic Retinitis. — In this affection the retina con- 
tains a number of small hemorrhages. They occur chiefly 
between the fibers of the inner layer, and consequently present 
a flame-like appearance as seen with the ophtJialnioscope. Any 
which lie in the outer layers are more apt to be round or 
irregular in shape. In addition to the hemorrhages there is 
diffuse opacity of the retina, and sometimes white spots of 
degeneration. The papilla is often much swollen, and the 
retinal veins distended and tortuous, while the arteries are 
small ; but these appearances, as well as the number of the 
hemorrhages, vary much in different cases. When there are 
but few hemorrhages they are situated in the neighborhood 
of the papilla and macula lutea. The appearances occasion- 
ally resemble those of albuminuric retinitis, but in the latter, 
as a rule, the proportion of white spots to hemorrhages is 
greater than in this affection. Probably many cases described 
as hemorrhagic retinitis are due to thrombosis of the central 
vein. (See p. 440.) 

Causes. — The affection is found most commonly in connec- 
tion with cardiac disease; e.g., valvular insufficiency, and 
hypertrophy of the left ventricle ; or with diseases of the vas- 
cular system ; e. g., atheroma, and aneurysms of the large 
vessels. Where it is due to disease of the coats of the arteries, 
the ophthalmoscope will occasionally reveal an arterial branch 
altered to the appearance of a white thread ; but usually the 
degenerative change does not interfere with the transparency 
of the vascular coats. In the majority of cases dependent on 
cardiac or vascular disease the retinal affection is monocular, 



THE RETINA. 429 

This, and the frequently sudden onset of the retinitis, led 
Leber * to think that some second factor for its occurrence 
exists, probably multiple embolisms, of the small branches of 
the central artery. Suppression of menstruation, or other 
wonted discharge, such as that from piles, has been observed 
as an immediate cause of hemorrhagic retinitis. 

A peculiar form of hemorrhagic retinitis is sometimes asso- 
ciated with secondar}' syphilis. In addition to the usual 
opacit}' of the retina in syphilitic retinitis (inde infj-a), a por- 
tion of the retina is co\'ered with numbers of small round 
hemorrhages h'ing in the different layers of the retina, while 
a connective-tissue development is occasionally found in the 
nerve-fiber layer, in the form of white striae along the course 
of the blood-vessels. 

The disturbance of vision is considerable, especially if the 
neighborhood of the macula lutea be much involved. 

The prognosis i:^ bad in severe cases of hemorrhagic retin- 
itis. Relapses are common, while the ultimate tendency is 
toward atroph}' of the retina and papilla. In very mild cases 
recoveiy may come about. 

The treatment must be chiefly expectant, or directed at 
most toward procuring rest for the general system, or for 
the organ primarih' at fault. Dr\' cupping on the temple, hot 
foot-baths, and iodid of potassium internally may be employed. 

Retinitis albuminurica occurs as a complication in man\' 
cases both of acute and chronic nephritis, and in the albu- 
minuria of pregnancy. It is most common with the small 
granular kidney, but may attend any chronic form of Bright' s 
disease. It occurs in six or seven per cent, of the cases. f 
Simon % has found t}'pical violet-blindness in retinitis albu- 

* "Graefe und Saemisch's Handbuch," Bd. v, p. 570. 

t Berger, "Maladie des Yeux et pathologic generale," Paris, 1893, p. 246. 

%Centralbl. f. Atigenheilk.,lsl2.Y , l?>()^, p. I32. 



430 DISEASES OF THE EYE. 

minurica, and considers this not rare, and a symptom charac- 
teristic of the affection. 

TJie defect of vision in the chronic form, ahhough often an 
early or even the first symptom, is never associated with an 
early stage of the kidney disease, but rather with a late stage 
of it, and with dilated left ventricle. Both eyes, as a rule,* 
are affected, although often not equally so ; vision is much 
lowered, and even perception of light may be wanting ; but 
the blindness is not always all due to organic changes in the 
retina, being often largely the result of uremia. 

Ophthalmoscopic Appearances. — These are venous hyperemia 
and swelling of the papilla, and of the retina in its neighbor- 
hood ; hemorrhages on the papilla, and in the nerve-fiber 
layer of the retina ; and round or irregularly shaped white 
spots in the retina, arranged in a zone around the papilla, 
some three papilla diameters from it. These changes take 
place in the order in which I have enumerated them. The 
hyperemia and engorgement of the veins, often very great, be- 
come less according as the white spots become more developed. 
Near the macula lutea no very coarse changes usually occur ; 
but fine white dots are found, with a star-like arrangement 
converging toward the macula. In some cases the spots 
spread out only on the inner side of the macula toward the 
papilla. The degree in which all these different changes are 
present varies in different cases, no one of them being pathog- 
nomonic of the kidney affection, but rather the grouping of 
the whole picture being suggestive. Sometimes the papillitis 
is so intense as to simulate that formerly known as congestion 
papilla in cases of intracranial tumor ; while the white spots 
are sometimes developed to such a degree as to become con- 
fluent and to form one large white plaque. Again, the 



* A few cases are recorded in which only one eye was attacked, and in several 
of these it was found that but one kidney was present. 



THE RETINA. 431 

papillitis, or white spots, or both, may be but slightly marked. 
The number and size of the hemorrhages are also liable to 
great variation. Detachment of the retina has been observed 
in a few cases, and in some the hemorrhages burst into the 
vitreous humor. 

Some of the white spots are caused by fatty degeneration 
of the outer layers of the retina (the retinal vessels passing 
over them"), others by hypertrophy of the nerve-fiber layer 
(the retinal vessels hidden by them j. The fine dots about the 
macula lutea are the result of fatty degeneration of the inner 
ends of ^fuller's fibers. Small aneur}'smal dilatations of the 
arteries occur ver}' occasionally. 

The connection between the renal and retinal affections is 
not known with certaint}*, but the theor\- that the latter is due 
to chronic uremia is probably correct. 

Prognosis. — In these cases the prognosis, as regards the 
patient's life, is bad. The majority die within eighteen months 
or two years ; but if the general disease remains stationary-, 
or improves, or recovers, the retinal changes may improve or 
disappear, and may leave the retina with noiTnal appearances 
and functions ; or the swelling, hyperemia, white spots, and 
hemorrhages may give place to optic atrophy, with diminution 
in size of the arteries, pigmentar\- alterations in the retina, and 
blindness. 

Treatment. — Dr}- cupping at the temple is about the onl\- 
remedy which can be employed directly for the retinal affec- 
tion, and I will not say that it is of much use. Taking into 
consideration the serious import of this eye-symptom for the 
life of the patient, it is a question whether, in many cases of 
pregnancy with albuminuric retinitis, abortion should not be 
resorted to, especially if the pregnancy have still some months 
to run. But on the whole the prognosis is more favorable in 
the albuminuria of pregnancy than in interstitial nephritis. 
Complete recovery has been observed. 



432 DISEASES OF THE EYE. 

Retinal Affections in Diabetes. — There is no one con- 
dition of the retina characteristic of diabetes, although un- 
doubtedly retinal affections occasionally do complicate it 
in an advanced stage. Small retinal hemorrhages, with fine 
changes in the form of glistening dots, about the macula 
lutea, somewhat similar in appearance to those which occur in 
Bright' s disease, except that they rarely form the well-marked 
star, are perhaps the most common and suggestive appear- 
ances. In other cases retinal hemorrhages alone are found, 
and in others hemorrhagic retinitis ; while, again, the so-called 
typical appearances of Bright's disease may be presented. 
There are often opacities of hemorrhagic origin in the vitreous 
humor, and iritis may come on. Leber lays down the im- 
portant rule that in all cases of retinal hemorrhages and of 
retinitis haemorrhagica the urine should be examined for sugar. 

Retinitis Leuksemica. — In not more than one-third or 
one-fourth (Leber) of the cases of leukocythemia does a retinal 
affection occur, and it is not always of the same type. It 
may consist in a slight diffuse retinitis, accompanied by some 
extravasations of pale blood ; while the blood-vessels are also 
pale, the veins being much enlarged, and rather flattened than 
over-distended ; the arteries small, and the choroid of an 
orange-yellow color. Or it may resemble a case of ordinary 
hemorrhagic retinitis. 

TJie appearances most cJiaracteristic of the affection are : a 
pale papilla with indistinct margins ; slight opacity of the 
retina, especially along the vessels ; small hemorrhages ; 
round, white, elevated spots up to two mm. in diameter, with 
a hemorrhagic halo, situated by preference toward the peri- 
phery of the fundus and at the macula lutea, but not at all, 
or only in very severe cases in the zone between the macula 
and the equator of the eye. These white spots consist of 
extravasations of leukemic blood, the result, Leber thinks, of 
diapedesis. 



THE RETINA. 433 

Vision maybe but little affected if the macula lutea be fairly 
free. Hemorrhage into the vitreous humor may cause com- 
plete blindness. 

Retinitis Punctata Albescens (Mooren) ; Retinitis Cen- 
tralis Punctata et Striata (Hirschberg). — A few cases of 
this peculiar affection have been described.* These have oc- 
curred in middle-aged or elderly people, whose general health 
was good ; or, if disordered, was not similarly so in any two 
cases. The defect of vision may come on rapidly, or may be 
gradually developed in the course of many years. It consists 
in a lowering of the central vision, with positive or relative 
scotoma ; but the eccentric field remains intact. 

The ophthalmoscope discovers great numbers, of minute 
white glistening dots and fine white striae in the retina, chiefly 
between the papilla and macula. A retinal hemorrhage was 
noted in one case, and in only one was slight papillitis present. 
The affection is probably of inflammatory origin. 

Treatment consisted in Heurteloup's leech, iodid of potas- 
sium, protection of the eyes, and care of the general health. 
Cure took place in one case, while in no instance did serious 
blindness come on. 

Development of Connective Tissue in the Retina, or 
Retinitis Proliferans. — Extensive white strise, formed of con- 
nective tissue, are sometimes seen in the retina, and may even 
conceal the vessels and papilla. They are the result of hemor- 
rhages, traumatic or otherwise, according to Leber, and of an 
inflammatory process according to Manz, and are formed by 
proliferation of Miiller's fibers and new growth of connective 
tissue. t Hemorrhages in the retina, or in the vitreous humor, 
or in both, are generally present at some period (p. 415). 



* Mooren, " P^iinf Lustren Ophthalmologischer Wirksamkeit," p. 216. 
Hirschberg, Centralblatt f. prak. Aiigenheilkunde, 1 882, p. 330. 
I Banholzer, Archives of Ophthal. , xxii, ii, p. 212. 



434 DISEASES OF THE EYE. 

Vision is often but slightly affected, but the danger of recur- 
rent intraocular hemorrhages renders the ultimate prognosis 
bad as a rule. 

Treatment. — Heurteloup's leech. lodid of potassium, or 
perchlorid of mercury. Protection-spectacles. 

Retinitis circinata is a rare disease, first described by 
Fuchs.* It occurs in old people, chiefly women, and is char- 
acterized by very remarkable appearances. At the macula is 
a gray or yellowish cloudy patch, which may attain the size 
of the papilla, and sometimes presents hemorrhages on its 
surface ; surrounding this, but separated from it by a healthy 
zone, is a ring composed of numerous, closely set, small white 
spots, which are confluent in places. According to de 
Wecker f this disease is only the result of a variety of hem- 
orrhagic retinitis. 

Purulent retinitis is observed as the result of septic em- 
bolism of the retinal arteries in septicemia after surgical op- 
erations, etc., and very frequently in cases of metria, and it is 
usually, in the latter condition, a fatal sign. 

In an early stage the oplitliabnoscope shows a number of 
small hemorrhages in the retina, with general cloudiness of 
the retinal tissues, while the actual embolisms, which are usu- 
ally multiple, may not be visible. 

The inflammation makes rapid progress, soon destroying 
sight, and extending to the choroid, iris, and vitreous humor, 
until finally panophthalmitis is reached. The retina is some- 
times alone the primary seat of the embolic attack, and some- 
times the choroid is also involved. The embolisms are often 
little more than masses of micrococci. 

The retina becomes secondarily implicated in many puru- 
lent processes which commence in other parts of the eye. 

* Von Graefe's Archiv, Vol. xxxix, pt. iii, p. 227. 
■\ Arc/iivd' Op/i/hnhtiolflgie, January, 1894. 



THE RETINA. 435 

Atrophy of the Retina. 

Atrophy or degeneration of the retina is characterized by 
diminution, or even complete obhteration, of the retinal ves- 
sels, accompanied by more or less atrophy of the papilla. It 
may be caused by severe forms of retinitis, and also by em- 
bolism or thrombosis. 

Retinitis pigmentosa is a degenerative rather than an in- 
flammatory affection of the retina. It is extremely chronic 
in its progress, coming on most commonly in childhood, and 
often resulting in complete, or almost complete, bhndness in 
advanced life. 

Vision is much affected, but the symptom most complained 
of is night-blindness (nyctalopia = vM, night ; 0)9'-, the eye), 
due rather to defective power of retinal adaptation than to de- 
fective light-sense. The field of vision, moreover, becomes 
gradually contracted, until only a very small central portion 
remains ; so that, although the patient may still be able to 
read, he cannot find his way alone — a function for which the 
eccentric parts of the field are the most important. An an- 
nular defect in the field is seen in some cases. Finally, the 
last remaining central region becomes blind. 

T/ic ophthalmoscopic appearances consist in a pigmentation 
of the nerve- fiber layer of the retina, which commences in the 
periphery, but not at its extreme limits, and in the course of 
years advances toward the macula lutea. The pigment is ar- 
ranged in stellate spots, of which the processes intercommu- 
nicate, so that the appearance reminds one of a drawing of the 
Haversian system of bone. Pigment is also deposited along 
the course of many of the vessels, hiding them from view. 
The degree of pigmentation varies much, and in some cases is 
quite absent, and the diagnosis then has to depend upon the 
other appearances and on the s\'mptoms. The papilla is of a 
grayish-yellow color, never white, and the vessels are veiy 
small. 



436 DISEASES OF THE EYE. 

The choroid is sometimes shghtly affected, irregularity, in 
its pigmentation being observable. 

Pathology. — The pigment in the retina is believed to wander 
into it from the pigment-epithelium layer. The other patho- 
logic changes in the retina consist in hyperplasia of its con- 
nective-tissue elements, and thickening of the walls of the 
vessels at the expense of their lumen. 

The choroid vessels, too, are altered,* owing to an endar- 
teritis, which causes hypertrophy of their coats, with more or 
less obliteration of their lumen. In fact, it seems probable 
that the primary seat of the diseased process is in the choroid ; 
and that it is the changes in it which cause the pigment from 
the pigment-epithelium layer to wander into the retina. 

Causes. — Retinitis pigmentosa often affects more than one 
member of a family ; and the patients, too, are frequently de- 
fective in intelligence or deaf and dumb. Many of them are 
the offspring of marriages of consanguinity, and in others an 
inherited syphilitic taint is present, while in others no cause 
can be assigned. Other congenital defects, supernumerary 
digits, etc., are sometimes present. 

Treatment is of little use. At best, one may stimulate the 
torpid retina by hypodermic injections of strychnin or with 
the continuous current. The latter means has found an 
advocate in Dr. Marcus Gunn,t and I have seen several cases 
in which temporary benefit was obtained from it. 

Diseases of the Retinal Vessels. 

Apoplexy of the Retina. — This differs from hemorrhagic 
retinitis in that the hemorrhages are found in a retina free from 
other diseased appearances, especially no retinitis. 

With the ophthalmoscope the extravasations of blood appear 



* Wagenmann, A. von Graefe' s Archiv, xxxvii, i, p. 230. 
^ Ophthat. Hasp. Rtp.,Wo\. x, p. 161. 



THE RETINA. 



437 



as red, or almost black, spots of various sizes and shapes. 
Their number and position in the fundus are also variable. 
The}' may be in any layer of the retina, and may sometimes 
burst into the vitreous humor, and sometimes become ex- 
travasated between the retina and choroid. 

Vision is interfered with according to the position and 
extent of the hemorrhages. Wherever an apoplexy be 
situated, the function of the retina at that place is suspended. 
If it be at the macula lutea, central vision will be seriously 
impaired ; while the scotoma produced by an apoplexy at 
the peripher}- of the fundus may pass unnoticed b\- the patient. 

Causes. — Retinal apoplexies are most common in advanced 
life, with atheroma of the blood-vessels, and are then valuable 
as a warning of possibly impending cerebral mischief Other 
causes are : Hypertrophy of the left ventricle ; suppression or 
irregularity of menstruation, or at the climacteric period ; the 
sudden reduction of tension of the eyeball after iridectomy for 
glaucoma ; the gouty diathesis (Hutchinson) ; progressive per- 
nicious anemia or anemia from loss of blood (hematemesis, 
etc.), or from exhausting diseases. In connection with this 
latter cause of retinal apoplexy, Stephen Mackenzie has pointed 
out '^' that when the corpuscular richness of the blood falls 
below 50 per cent., whate\-er the cause of the anemia, the 
tendency to retinal hemorrhage is present. 

In young people of both sexes, from the fourteenth to the 
twentieth year of age, large retinal apoplexies, which may 
extravasate into the vitreous humor, are sometimes seen, and 
it is difficult to assign a cause for them. Some of the subjects 
are weak or anemic, while many of them are in perfect health. 
Neither Eales t nor Xieden T has found these apoplexies in 

* Trayis. Ophthal. Sac. U. K., December 13, 1883. 

t Ophthal. Review, 1882, p. 41. 

X Bericht d. Ophthal. Gesellsch., 1882. 



438 DISEASES OF THE EYE. 

young women ; but this does not conform with my experience, 
nor with that of many others. Eales has noted irregukir 
circulation, epistaxis, and constipation in these cases. 

Prognosis. — The apoplexies are observed, in the course of 
weeks or months, to become paler and smaller, often leaving 
after them choroid changes, or grayish spots dependent on 
degeneration of the retina, and in some extreme cases atrophy 
of the whole retina may result. 

Occasionally absorption of the hemorrhages is accompanied 
by complete restoration of vision, but usually the scotomata 
remain. Recurrences of the hemorrhages are very common. 
Glaucoma comes on as consecutive to retinal apoplexies in 
some instances, and is then known as hemorrhagic glaucoma, 
an incurable form of the disease (p. 361). 

In other cases the hemorrhage, having invaded the vitreous 
humor, gives rise to dense, permanent opacity in it, followed, 
perhaps, by detachment of the retina. 

Treatment. — Active measures are of little use. Cold com- 
presses at first, with a pressure bandage and dry cupping to 
the temple, may be employed. The general state of the patient 
must be attended to, and no violent muscular efforts permitted. 

Embolism of the Central Artery of the Retina. ^Sud- 
den or very rapid blindness, beginning at the periphery of the 
field, and advancing toward the center, is the only symptom 
experienced by the patient. 

Immediately after the attack, the oplitJialinoscope shows a 
marked pallor of the papilla, while the artery and its branches 
are empty of blood, resembling fine white threads, and the 
veins are diminished in size at the papilla, but increase some- 
what toward the periphery. Pressure on the eyeball produces 
no pulsation nor change in caliber of the vessels, as it does in 
a sound eye. Usually, on the following day, the central 
region of the retina begins to assume a grayish-white, opaque 
appearance, consequent on disturbance of nutrition, in the 



THE RETINA. • 439 

midst of which the macula lutea is seen as a purple-red spot. 
De Schweinitz has seen this cherry-red spot at the macula 
twenty minutes after the embohsm took place. The little 
blood contained in the vessels may soon be seen divided into 
short columns with colorless interspaces, and these move 
along the vessels with a slow, jerky motion. Minute hemor- 
rhages often occur, most commonly between the macula and 
the papilla. 

The peculiar appearance of the macula lutea is certainly 
not due to hemorrhage. According to Liebreich, it is merely 
a contrast effect, the red color of the choroid shining through, 
where no nerve-fiber layer is present. Leber suggests that 
the color may be due to the retinal purple. 

The infiltration of the retina passes away in a few weeks, 
and also the peculiar appearance of the macula lutea, while 
atrophy of the retina and papilla usually supervenes. 

Embolism of a branch only of the central artery has been 
observed. In these cases the infiltration and the defect of 
vision are confined to the part of the retina supplied by the 
embolized branch. 

Prognosis. — Vision may improve for a time, but when atro- 
phy commences it falls back again, and finally power of per- 
ception of light is lost. Cases of embolism of a branch are 
more likely to recover. 

Causes. — Endocarditis ; mitral disease ; atheroma of the 
large arteries of the body ; aneurysm of the aorta ; pregnancy ; 
Bright's disease. Two cases of chorea with embolism of the 
central artery are recorded.* But it is said also to occur in 
healthy persons without any discoverable cause. 

Treatment. — Repeated paracentesis of the anterior chamber 
has been tried, and also iridectomy, with the object of reduc- 



*H. R. Swanzy, R. L. O. H. Reports, September, 1875; and A. Benson, 

Ophthal. Review, January, 1886. 



440 DISEASES OF THE EYE. 

ing the tension, and in this way promoting a collateral flow of 
blood, by means of the only ascertained (Leber) communica- 
tions between the retinal and choroid vascular systems — 
namely, at the entrance of the optic nerve.* These attempts 
have been unsuccessful. 

Several cases have been published in which the circulation 
which probably was not completely impeded by the embolus, 
was restored and good vision regained, the recovery being 
probably due to the manipulations of the eyeball made in each 
case for the purpose of observing the effect of pressure on the 
vessels. So long as the pressure was maintained, a column of 
blood was being stored up behind the embolus, and, on re- 
moval of the pressure, it rushed forward against the impedi- 
ment, carrying the latter into some more remote vessel or into 
the general vascular system. In fresh cases massage of the 
eyeball, suitably applied, would, therefore, always be worth the 
trial. 

Thrombosis of the Retinal Artery. — Blocking of the 
artery may occur spontaneously, from thrombosis due to 
failure of the heart's action and slowing of the arterial flow, 
the result, in its turn, of cardiac disease, spasm of the blood- 
vessels, disease of the walls of the vessels, or alterations in the 
quantity and amount of blood. 

The oplitJialiiioscopic signs are in all respects similar to those 
of embolism. 

The diagnosis between thrombosis and embolism of the 



* Cowers ("Manual of Medical Ophthalmoscopy,"' p. 31) is of opinion that 
there are other anastomoses between these systems, probably by connection with 
the long ciliary arteries. A cilioretinal vessel, passing from the choroid or sclerotic 
at the papilla to the region of the macula lutea, is not an uncommon vascular 
anomaly; and Benson has published a case of embolism [OphthaL Hosp. Rep., 
Vol. X, p. 336) in which the presence of such an artery seemed to have a favor- 
able influence for the progress of the case, good central vision being recovered, 
although the field remained concentrically contracted. 



THE RETINA. 441 

central artery can only be made by certain symptoms, which 
precede or accompany the attack m thrombosis, but are want- 
ing in embolism. These are : previous attacks of transient 
blindness in the blind eye ; a simultaneous attack of blindness 
in the fellow eye ; and faintness, giddiness, and headache at 
the onset of the blindness. 

Treatment. — When transient attacks of blindness are com- 
plained of, it is important to overhaul the patient's general 
state, and to correct, so far as possible, any condition which 
might be the cause of feeble circulation. When the true 
attack comes on, manipulation of the eyeball applied immedi- 
ately, or paracentesis of the anterior chamber, might prove of 
use. 

Thrombosis of the retinal vein, the occurrence of which 
was first proved anatomically by Michel, is seen chiefly in old 
people with atheromatous arteries or cardiac troubles. Orbi- 
tal cellulitis, from erysipelas or other causes, may also produce 
it. 

The ophtliahnoscopic appearances are : Extreme engorgement 
of the retinal veins, with great narrowing of the arteries ; the 
whole fundus is thickly studded with dark hemorrhages ; the 
optic papilla after a time becomes pale, and undergoes atrophy, 
and the hemorrhages, having become absorbed, leave an 
atrophied retina with thready arteries. 

TJie prognosis is very bad, sight becomes permanently 
damaged or lost, and the treatment can only be directed to the 
general condition. 

Aneurysm of the central artery of the retina occurs 
either as a relatively large dilatation on the main branches 
of the arter}^ (a very rare condition),* or as small miliary 
aneurysms, which may indicate the presence of others in the 
small arteries of the brain. Two interesting cases of the latter 

* Sous, An7iales d'' OctiL, 1865, liii, p. 241. 
37 



442 DISEASES OF THE EYE. 

kind have been recorded, one by Story and Benson,* and the 
other by Permow,t in men aged respectively twenty and forty. 
In one of these cases there were also extensiv^e connective- 
tissue changes in the retina, the veins were dilated in places, 
and only one eye was affected. The minute aneurysmal dilata- 
tions were globular, and situated laterally on the vessels ; or 
they were fusiform, and involved the whole of its lumen. 
The number of aneurysms in an eye varied from three to nine. 
Neither case was followed to its end ; but it is to be presumed 
that such eyes would run great risk of being ultimately lost 
through intraocular hemorrhage. 

A rational treatment iox\\i^ condition can hardly be devised. 

Sclerosis of the retinal vessels (perivasculitis, or, more 
rarely, endarteritis) reveals its presence by narrowing of the 
blood column and by the appearance of white lines along the 
vessels. It usually begins in the large trunks on the papilla, 
and may not extend much beyond the latter, as in some cases 
of optic atrophy ; while in other cases (Bright' s disease, heredi- 
tary syphilis) it involves the small branches as well, and may 
even lead to obliteration of the lumen of the vessels, so that 
they look like white branching streaks. The arteries are 
more liable to this condition than the veins. 

Quinin Amaurosis. — Quinin in large doses, and ver}- 
occasionally in small doses, is liable in some individuals to 
cause amblyopia, which may amount to absolute blindness, 
accompanied for some hours or days by great deafness. This 
absolute blindness is never more than temporary, although it 
may last for some weeks ; but in severe cases concentric con- 
traction of the field is apt to remain permanently, witli or 
without some defect of central vision. In the only instance 
of this more serious result w^iich I have seen, the color- and 

* Trans. Ophthal. Soc, 1883, p. 108. 

^ Centralbl. f. Aiigenheilkunde, 1883, p. 392. 



THE RETINA. 443 

light-senses, notwithstanding the contracted field and marked 
seeming optic atrophy, were normal ; but the adaptation of 
the retina, as shown by considerable night-blindness, was 
defective. 

In what may be called the acute stage, the ophthalmoscopic 
appearances are sometimes normal, but pallor of the optic 
papilla, with scarcity and smallness of the retinal vessels, is 
the usual condition. Where the case is chronic — the fields 
remaining contracted, although central vision has improved 
— the ophthalmoscope may discover a very pale optic papilla 
with minimal vessels. 

The retinal ischemia is doubtless the immediate cause of the 
amblyopia, and in its turn is the result of diminished heart's 
action and lowered arterial tension, both of which have been 
shown to be produced by large doses of quinin. 

Treatment. — Cessation of the use of the quinin. Digitalis 
internally, to raise the arterial tension, nitroglycerin or inhala- 
tions of nitrite of amyl, hypodermic injections of strychnin, 
and general tonic treatment are the means most likely to pro- 
mote a cure. 

Injury of the Retina by Strong Light. 

Blinding of the Retina by Direct Sunlight. — This is 
especially likely to occur on the occasion of solar eclipses, by 
observation with unprotected eye. 

Immediately after the exposure the patients complain of a 
dark or semi-blind spot in the center of the field of vision — a 
positive scotoma, in short, which may even be absolute, and 
which interferes with vision in proportion to the length of the 
exposure. There may also be a central defect for colors, 
which may extend over a larger area.* A peculiar oscilla- 



*Mackay, Ophihal. Review, 1894, January, February, and March. A very 
interesting paper, which contains abstracts of all reported cases. 



444 DISEASES OF THE EYE. 

tion or rotatory movement is frequently observed in the sco- 
toma, and is very persistent. Objects may also seem twisted 
or otherwise distorted (metamorphopsia). 

Tlie opJitJialvwscopic appcarcuices may be normal, but as a 
rule some changes exist, such as an alteration or loss of the 
Hght reflex at the macula, or a minute pale orange spot near 
the fovea, with, especially in the later stages, some darkening 
or pigmentation. When the cases are not severe, improve- 
ment in vision takes place, but complete recovery is not com- 
mon. Hitherto no case in which the vision had been reduced 
to less than ^ has regained -|. 

Czerny, and also Deutschmann,* demonstrated that concen- 
tration of the direct rays of the sun on the rabbit's retina 
gives rise to coagulation of the retinal albumin, with vascular 
reaction, diapedesis of blood corpuscles, and pigmentary dis- 
turbances. A bright white spot, with a dark red ring sur- 
rounding it, was seen with the ophthalmoscope. But the 
changes in the human retina produced by exposure to direct 
sunlight are not of similar nature, for, as has been shown by 
Widmark,t the intensity of light employed by those experi- 
menters was much greater than in the clinical cases, the heat 
being sufficient to blister the skin. 

Treatment. — Hypodermic injections of strychnin, the con- 
stant galvanic current, and dry cupping on the temple afford 
the best chances for promoting the cure. Rest and dark pro- 
tection-glasses are very important. 

Snow-blindness. — Exposure of the unprotected eyes for 
a length of time to the glare from an extensive surface of 
snow produces in some persons a peculiar form of ophthalmia, 
which may be followed by temporary or even permanent am- 
blyopia. Although this condition is chiefly an affection of the 

* ^. von Graefe's Archiv, Bd. xxviii, Abt. iii, p. 241. 
t iVordJsk. Ophthal. Tidsskrift., Vol. ii. 



THE RETINA. 445 

conjunctiva, it is described here in order to compare it with the 
effects of sunlight and electric light. 

Snow-blindness begins with sensations of a foreign body in 
the eye, photophobia, blepharospasm, and lacrimation ; later 
on chemosis, with small opacities, or ulcers, of the cornea, 
comes on. The condition passes off in three or four days 
without leaving any permanent bad results, except in rare cases, 
when there may be some secondary hyperemia of the retina. 

Treatment. — The preventive treatment consists in the wear- 
ing of dark smoked glasses when traveling on the snow ; 
w^hile for the ophthalmia cold applications and cocain are re- 
commended, to relieve the distressing symptoms. 

Effects of Electric Light on the Eyes. — The degree of 
intensity of light required to produce injurious effects on the 
eye is not known ; but this much is certain, that no bad re- 
sults have been observed from the ordinary use of the incan- 
descent light.* Two groups of symptoms are observed from 
the action of a strong electric light on the eyes. 

{a) Electric OphtJialniia. — This has been chiefly seen in 
those employed in electric welding operations, and less fre- 
quently in electricians who use strong arc-light. f The symp- 
toms begin shortly after exposure to the light, always within 
twenty-four hours, and are the same as those present in snow- 
blindness ; the lids also are swollen, and even erythematous 
at times. The pupils are contracted. A slight mucopuru- 
lent secretion from the conjunctiva appears after the subsi- 
dence of the above symptoms. Recovery takes place in a 
few days, with complete restoration of vision, except in rare 
cases. 

ip) Blinding of the Retina. — This is the same affection as 
in blinding of the retina by sunlight. The central scotoma 

*Hartridge, Brit. Med. Jour., February, 1892, p. 382. 

t Hewetson, Brit. Med. Journ., June, 1893, p. I315. Berger, loc. cit., p. 435, 



446 DISEASES OF THE EYE. 

may persist after an attack of electric ophthalmia, or may oc- 
cur without it. The injurious action of the electric light on 
the eye has been attributed to the chemic action of the ultra- 
violet rays, to the accompanying heat rays, and to dazzling of 
the retina. Widmark's experiments show that changes can 
be produced in the retina by the electric light, without any 
heat coagulation. These changes consist in edema, with 
more or less destruction of the nervous elements of the retina, 
namely, the outer layers, including the rods and cones, and 
the inner layer of nerve-fibers. 

Treatment. — The preventive treatment consists in the use 
of colored glasses. Yellow glass has been recommended by 
Maklakoff. In the electric welding works in Germany, a com- 
bination of deep blue and red is used, while the Sheffield 
workers prefer several layers of ruby glass. For the rest of 
the treatment see snow-blindness, and blinding by sunlight. 

It may be as well to mention here that for domestic illu- 
minating purposes electric light possesses many advantages 
over gas, so far as the use of the eye is concerned. It has a 
greater illuminating power, produces less heat, and no products 
of combustion, and hence it does not vitiate the atmosphere, 
or tend to cause conjunctival irritation. The electric light is 
much steadier than gas ; and, on account of the smaller 
quantity of red rays which it emits, it forms a nearer approach 
to sunlight than does gas. 

Tumor of the Retina. 

Glioma of the Retina. — This is a malignant growth which 

is found almost exclusively in young children,* and may even 

be congenital. It is the only growth which occurs in the 

retina. Owing to the age of the patients, the incipient stages 



* A case of glioma retinae in a man aged twenty-one is reported by Mervill in 
the Trans. Ainencon Ophthal. Soc.,\o\. iii., p. 364. 



THE RETINA. 447 

of the disease are seldom observed, for they are unattended 
by pain or inflammation. 

The growth commences as small, white, disseminated swell- 
ings in the retina, usually in one or other of the granular 
layers, more rarely in the nerve-fiber layer. The retina is apt 
to become detached at an early period ; but there are excep- 
tions to this, especially when the disease starts from the nerve- 
fiber layer. In the early stages there is no iritis, cyclitis, or 
opacity of the vitreous humor, and the iris periphery is not 
retracted — points which especially enable us to distinguish 
it from pseudoglioma (vide Purulent Inflammation of the 
Vitreous Humor, Chap, xiv, p. 414). Secondary glaucoma 
finally comes on. The optic nerve may become involved at 
an early period ; but, sooner or later, it invariably does so, lead- 
ing then to glioma of the brain. When the tumor has filled 
the eyeball, it bursts outward, usually at the corneosclerotic 
margin, and then grows more rapidly, and often to an immense 
size, as a fungus hxmatodes. The orbital tissues become in- 
volved, and even the bony walls of the orbit ; while secondary 
growths in other organs, more especially in the liver, are not rare. 

The diagnosis between glioma of the retina and tubercle of 
the choroid (p. 3ii),w^hen the latter occurs in young children, 
is sometimes difficult or impossible, but, in view of treatment, 
not of great importance, as in either case the eye must be 
enucleated. 

Treatment. — The only hope of saving the patient's life lies 
in enucleation at an early stage, or before the optic nerve 
becomes diseased. It is important in removing the eyeball to 
divide the nerve as far back as possible ; and if the orbital 
tissues be already diseased, to remove all suspicious portions 
of them. Several cases in which there was no return of the 
gro^vth have been observed.* 

* Lagrange, "Etudes sur les Tumeurs de I'CEil," etc., 1893, p. 160. 



448 DISEASES OF THE EYE. 

Parasitic Disease. 

Cysticercus under the Retina. — The cysticercus of the 
taenia solium in the eye is extremely rare in these countries, 
but not so in Germany. Its most frequent seat is between the 
retina and choroid, where it is recognized with the ophthal- 
moscope as a sharply defined bluish-white body, with bright 
orange margin. At one point of the cyst there is a very 
bright spot, which corresponds with the head of the entozoon. 
Wave-like motions along the contour of the cyst should be 
looked for to confirm the diagnosis. The cysticercus may 
move from its original position, and in so doing cause consid- 
erable detachment of the retina. Delicate veil-like opacities 
are apt to form in the vitreous humor, and are almost charac- 
teristic of the presence of cysticercus. 

The entozoon may become encapsuled behind the retina ; 
or it may burst into the vitreous humor (p. 422) ; and, finally, 
chronic iridocyclitis, with total loss of sight and phthisis 
bulbi, is apt to come on. 

Treatment. — We are not acquainted with any anthelmintic 
which will act upon the entozoon in the eye. Removal of the 
cyst by operation is the only means by which the eye can be 
saved ; and this measure can only be resorted to when the 
position of the cysticercus admits of it. By a well-placed 
puncture through the sclerotic and choroid the entozoon may 
then be evacuated. 

Detachment of the Retina. 

This condition consists in a separation of the retina from 
the choroid, the intervening space being occupied by a clear 
serous fluid. It is not usual to employ the term when it is a 
solid neoplasm only that lies between retina and choroid. 

If the media be clear and the detached portion extensive 
the diaLHiosis is not difficult. 



i 



THE RP:TINA. 449 

TJic oplitJiahnoscope shows a grayish reflex from a position 
in front of the fundus ocuH, and to the surface from which 
the reflex is obtained a wave-hke motion is imparted when 
the eyeball is moved. Over this grayish surface the retinal 
vessels run, and they serve to distinguish a detached retina 
from any other diseased condition with a somewhat similar 
appearance. They seem black, not red, in consequence of 
absorption of the transmitted light, and are hidden from 
view here and there in the folds of the detached retina. In 
many cases a rent in the detached retina, through which the 
choroid can be discerned, will be discovered. 

The detachment may commence in any portion of the 
fundus, but most commonly above ; yet, owing to gravitation 
of the fluid, it ultimately settles in the lower half of the fundus, 
and hence this is the most common place to find it, the part 
first detached having become replaced. The diagnosis is more 
difficult if there be but little fluid behind the retina, or if there 
be opacities in the vitreous humor. 

Vision is affected according to the position and extent of 
the detachment. Central vision may be quite normal if the 
macula lutea and its immediate neighborhood are intact. 
The patients complain of seeing objects distorted, of a black 
veil which seems to hang over the sight, and sometimes of 
black floating spots before the eye, due to opacities in the 
vitreous humor. These symptoms often come on suddenly 
in an eye which has hitherto had good sight. 

The field of vision, on examination, will show a defect 
corresponding to the position of the detachment. If, for 
example, it be below, the defect will be in the upper part of 
the field. If the detachment be fresh, the retina not having 
yet undergone secondary changes, and if the quantity of 
subretinal fluid be not great, the defect in the field may only 
amount to an indistinctness of vision ; while later on, when 
infiltration and connective-tissue degeneration of the detached 
38 



450 DISEASES OF THE EYE. 

part come about, fingers may not be counted at the same 
place. The phosphenes * of the detached portion are wanting. 

Should the detachment become complete, little more than 
power of perception of light may be present. Total detach- 
ment is followed by cataract, and often by iritis and phthisis 
bulbi. The detachment may remain stationary, and not extend 
to the whole fundus, or the retina may return to its normal 
position. Such a happy result, however, is most rare. 

Causes. — Myopic eyes — which w^e know are so frequently 
affected with choroiditis and disease of the vitreous humor 
— are those most subject to detachment of the retina, but 
idiopathic detachment occurs also in eyes which are apparently 
healthy. Blows upon the eye may produce detachment, the 
retroretinal fluid being serous or bloody. Some punctured 
wounds of the sclerotic, also, in the course of healing, by 
dragging on the retina, give rise to it. Choroid tumors, 
especially those situated in the posterior segment of the 
fundus, usually cause detachment in an early stage of their 
growth, and the complication renders their diagnosis more 
difficult (p. 310). 

Leber f observed that in non-traumatic detachment a per- 
foration or rent in the detached portion is very frequently to 
be seen with the ophthalmoscope, and holds that it is probably 
always present, although sometimes, from being hidden be- 
hind a fold of the retina, it cannot be found. He was led 



* Phosphene is the subjective sensation of light experienced when the eyeball 
is pressed upon. For clinical purposes it is best tested by gentle pressure with a 
blunt point (head of a bodkin or large-sized probe) applied to the eyeball through 
the eyelid. The phosphene of any region is tested by applying pressure to that 
part of the globe ; thus, if in a healthy eye the individual look down, and press- 
ure be applied to the upper part of the globe through the eyelid, the phosphene 
will be seen appearing below, but if there be a detachment of the retina at the 
place pressed on, no phosphene is seen. 

t Bericht d. Ophthal. Geselhrh., 1882, p. 18. 



THE RETINA. 451 

from this, and from his pathologic investigations and experi- 
ments upon animals, to think that the detachment was due to 
shrinking of a diseased vitreous, which first became slightly 
separated from the retina, and that then, at some place where 
the retina and h\'aloid had become adherent from the inflam- 
matory process, a rent was produced in the retina by the 
shrinking process in the vitreous. And he concluded that 
through this rent the fluid, which is always present behind the 
vitreous in cases of detachment of that body, makes its way 
behind the retina, and separates the latter from the choroid. 
All this has been fully borne out by Nordenson's pathologic 
researches,* who has ascertained, moreover, that disease of 
the ciliary body and choroid is the primary cause, although 
we may not be always able to detect it with the ophthalmo- 
scope, and that the pathologic change in the vitreous humor 
.consists in an alteration in its connective-tissue elements, 
resultino- in the deleterious shrinking-. 

Raehlmann,t however, from the results of recent experi- 
ments, and also from clinical observation, concludes that de- 
tachment of the retina is due to exudation from the choroid 
vessels of a fluid which is more albuminous than the fluid in 
the vitreous humor. Hence, he thinks, diffusion takes place 
through the retina, and a greater quantity of the less albu- 
minous vitreous fluid passes through the retina^ thus pro- 
ducing and increasing the detachment. Rupture of the retina 
is not, in his view, a necessaiy factor in the causation, but it 
may occur if the tension behind the retina be higher than that 
in front of it. 

Treatment. — Evacuation of the subretinal fluid by puncture 
of the sclerotic was first proposed by Sichel, and has been 
cultivated by de Wecker. He uses an instrument like abroad 



"^ " Die Netzhautablosung," Wiesbaden, 1 887. 
■\ Archiv filr Ophthal., xxvii, part i, p. i. 



452 DISEASES OF THE EYE. 

needle, with a sharp point and two blunt edges, which is 
entered through the sclerotic and choroid at a place corre- 
sponding to the position of the detachment, but not so deeply 
as to reach the retina, lest thereby it be further displaced. 
The instrument is then given a quarter of a rotation, to make 
the wound gape, so as to admit of the flowing off of the 
fluid. If possible, a position near the equator of the globe, 
and between two recti muscles, should be selected for the 
operation. Moreover, the incision should lie parallel to the 
direction of the orbital muscles, so that the choroid vessels 
may be injured as little as possible. A firm bandage is 
applied, and the patient kept in bed for eight or ten days. 

The dorsal position in bed, with a pressure bandage on the 
eye, maintained for from four to six weeks, has produced re- 
position of the detachment in some cases. This method, if 
properly carried out, is most trying to the patient. 

The few cures which have been reported as accomplished 
by these means probably depended upon the retina again 
comin"; in contact with the choroid, and, owing- to some slig-ht 
inflammatory process, adhering to it. For the most part the 
cure is only temporary, and in such cases we may suppose 
that no adhesion sprang up, but that the temporary cure was 
due to a return of the subretinal fluid, through the hole in 
the retina, to its original position between the retina and 
vitreous. Soon, however, it makes its way back again through 
the opening, and the detachment recurs. 

Schoeler * injects tincture of iodin into the vitreous humor 
in front of the detached retina, in order to press it back to the 
choroid, and to produce a plastic choroidoretinitis, which 
may unite the two coats. He has reported several good 
results by this method, but some who have tried it have ex- 

* '* Zur operativen Behandlung und Heilung der Netzliautablosung," Berlin, 
1889. 



THE RETINA. 453 

perlenced violent inflammatory reaction in the eyes operated 
on, with disastrous consequences. 

Grossmann * tried aspiration of the subretinal fluid, with 
simultaneous increase of the pressure in the vitreous humor, 
by injections into the latter of four or five drops of an indif- 
ferent fluid — namely, a 0.75 per cent, lukewarm solution of 
common salt. The results obtained were encouraging in the 
three cases treated, but I am not aware of any further reports. 

Electrolysis has recently been tried. 

Galezowski f simply aspirates the subretinal fluid. 

Pilocarpin used hypodermically has been praised by some 
as a mode of treatment, as, also, salicylate of sodium intern- 
ally. 

Formerly an active mercurial treatment used to be em- 
ployed, with the object of obtaining absorption of the fluid. 

Tlie prognosis of every case of detached retina is bad, spon- 
taneous cure being extremely rare, and the treatment of the 
disease remaining one of the weakest points of ophthalmic 
therapeutics. Moreover, both eyes are often affected, one 
after the other. The cures by any one or by any combination 
of the above methods of treatment are few and far between ; 
and when, sometimes, the retina does return to its place, there 
is still the danger of a recurrence of the detachment. The 
most favorable cases are those due to choroiditis, the most 
unfavorable those due to posterior staphyloma. 

Traumatic Affections of the Retina. 

In addition to detachment and rupture of the retina, the 
undermentioned conditions occur as the results of injuries. 

Traumatic Anesthesia of the Retina. — A blow on the 
eye from a fist, cork from a bottle, etc., is Hable to produce 

* ophthalmic Review, 1 883, p. 89. 

t Recueil d ' Ophthalmologie, March, 1888. 



454 DISEASES OF THE EYE. 

considerable amblyopia, with concentric contraction of the 
field, which may continue for a long time, while the ophthal- 
moscopic appearances are normal. Ultimately these cases 
usually recover, an event which may be decidedly promoted 
by the use of strychnin hypodermically ; but very defective 
sight sometimes remains permanently. 

Commotio retinae, or traumatic edema of the retina, is 
the result of a blow upon the eye. Within a few hours after 
the accident, the ophtlialnioscope reveals a white cloudiness of 
a portion of the retina, usually in the neighborhood of the 
optic papilla and macula, but sometimes more eccentrically ; 
and sometimes there are two opaque patches. The opacity 
increases in intensity, and spreads somewhat. The retinal 
vessels remain normal ; there may be some small hemor- 
rhages, and sometimes the papilla is redder than normal. 
These appearances completely disappear in the course of a 
few days. Vision is only slightly affected, and recovers 
according as the retinal changes pass off. 



CHAPTER XVI. 

DISEASES OF THE OPTIC NERVE. 

Optic Neuritis. — The oplitJialinoscopic appearances of in- 
flammation of the optic nerve vary a good deal with tlie inten- 
sity of the process. Common to every case is hyperemia and 
swelhng of the papilla, with haziness (so called "woohness") of 
its margins, and increase in the size of the central vein, while the 
central artery remains of normal dimensions, or is contracted. 
The swelling and haziness extend but a short distance into 
the surrounding retina, and the distension of the vein is also 
not continued to the periphery of the fundus. In slight cases 
these appearances may barely exceed the normal. 

In extreme instances the papilla is swollen to a great size and 
may even assume quite a mushroom shape, while the veins 
are enormously distended and tortuous, and the arteries are 
contracted so as to be barely visible. Grayish striae, also, ex- 
tend from the papilla into the surrounding retina, some flame- 
shaped hemorrhages are present on or near the papilla, and, 
occasionally, white spots in the retina, and a stellate arrange- 
ment of small white dots about the macula lutea produce an 
appearance which cannot be distinguished from albuminuric 
retinitis. This extreme form is still sometimes termed con- 
gestion papilla, or choked disc (^Stainnigspapille), although 
the theory which originally suggested the term has been 
abandoned. Papillitis (inflammation of the optic papilla) is a 
better term, expressing, as it does, more truly the pathologic 
condition. 

The vision, even in cases where the ophthalmoscopic signs 

455 



456 DISEASES OF THE EYE. 

are highly developed, is frequently but little below the normal ; 
while, again, in other, and possibly less well-marked cases, in 
so far as the appearances are concerned, it may be reduced to 
perception of light, or even that may be wanting. When due 
to cerebral tumor the neuritis appears as a rule before the 
vision becomes affected. These remarkable differences in 
the degree of blindness depend, probably, on the extent to 
which the nervous elements of the inflamed part are pressed on 
or altered, and this cannot be gaged by the ophthalmoscopic 
appearances. 

Sometimes the field of vision is normal, while again it is 
concentrically or irregularly contracted, or it may be hemi- 
anopic. 

Attacks of temporary loss of sight, sometimes called epilepti- 
form amaurosis, is a very common symptom in cerebral tumors ; 
it may occur several times a day, and may last from a few 
minutes to half an hour. 

Pathologically, the changes in the papilla consist in venous 
hyperemia, edema, hypertrophy of the nerve-fibers, infiltration 
of lymph-cells, and development of connective tissue. Inflam- 
matory changes, although less pronounced, are also present in 
the trunk of the nerve and its sheaths. 

Causes. — Inflammation of the optic nerve is most commonly 
found in connection with coarse encephalic disease. A cerebral 
tumor (syphiloma, tubercle, glioma, and abscess) in particular 
is the most common cause, and is, moreover, usually present 
when the papillitis is of an intense kind (choked disc). The 
neuritis, except in very rare instances, is bilateral, and is one 
of the general symptoms. Hemianopia may coexist as a 
localizing symptom if the visual center or fibers on one side be 
involved. A very small tumor situated anywhere * in the 



* Hughlings Jackson [Trans. Ophihal. Soc, Vol. i, p. 79) states that optic 
neuritis has not been noted with tumors of the medulla oblonc^ata. Edmunds and 



THE OPTIC NERVE. 457 

brain is capable of producing optic neuritis, although un- 
attended by meningitis. Cerebral cysts do not often cause it. 

Tubercular meningitis is the next most common cause. 
Non-tubercular meningitis occasionally gives rise to optic neu- 
ritis, and sometimes, also, cerebrospinal meningitis does so. 

Optic -neuritis is occasionally associated with acute myelitis, 
so that inflammation of the optic nerve, with paralytic phe- 
nomena, does not exclusively indicate cerebral disease. 

The connection between optic neuritis and intracranial dis- 
eases has given rise to much discussion. In cases of tumor, 
as well as of tubercular meningitis, a considerable exudation 
of fluid usually takes place into the cavity of the third ventricle. 
This, along with the pressure of the new growth, or alone in 
cases of meningitis, increases the intracranial pressure. By 
reason of this increased pressure the subarachnoid fluid is be- 
lieved to be driven into the subvaginal lymph-space of the optic 
nerve, and to produce there that dropsy of the sheath which 
is found in nearly all these cases on careful postmortem exam- 
ination. 

Leber holds * that this fluid is probably an irritant, and as 
such sets up the inflammation, a view which has been corrobo- 
rated by Deutschmann.f 

The inflammation, although most intense at the papilla, near 
which the fluid is collected in greatest quantity in the culdesac 
formed by the termination of the intervaginal spaces, is not 
confined to that place, as w^as believed, but extends up the 
trunk of the nerve, as microscopic examination reveals. 

Many observers J state that in a large number of cases cere- 

Lawford (^Trans. Ophthal. Soc, Vol. iv, p. 185) find that tumors of the cortical 
motor area do not commonly produce neuritis, while it is very frequent and severe 
in tumors of the cerebellum. 

* Trans. Infej-nat. Med. Congress, 1881, Vol. iii, p. 52. 

f " Ueber Neuritis Optica," Jena, 1887. 

+ S. Mackenzie, "Brain," Vol. ii, p. 257. W. Edmunds, 7;-rt';«. Ophthal. Soc. ^ 
Vol. i, p. 112. Brailey, Trans. Internat. Med. Congress, 1881, Vol. ii, p. ill. 



458 DISEASES OF THE EYE. 

britis, recognizable only with the microscope, is present, and 
that an extension of this process down the optic nerve takes 
place. They have ascertained that the whole trunk of the 
nerve is involved in the inflammation, and they seem to regard 
the dropsy of the sheath as of little or no importance in the 
causation of the optic neuritis. 

Again, others * maintain that edema, but not inflammation, 
of the optic trunk is conducted from the brain. 

The view originated by von Graefe, that the extreme form 
of papillitis, called by him Statiiingspapille (choked disc), is due 
to obstructed outflow of blood through the retinal vein, is now 
abandoned. 

Other causes for optic neuritis are : 

Hydrocephalus. — Here the pathogenesis is probably the 
same as in the foregoing ; but the occurrence of optic neuritis 
is, on the whole, not very common in this connection. 

Tumors of the Orbit. — The path by which these growths 
bring about papillitis is still unknown. 

Inflammatory processes in the orbit, such as caries, inflam- 
mation of the retroorbital areolar tissue, erysipelas of the head 
and face extending to the orbital tissues, and periostitis. The 
presence of the latter may often be recognized by pain on 
motion of the eyeball, pain in the eye and forehead, and espe- 
cially by pain on pressure of the globe backward, and is fre- 
quently of rheumatic origin. Often in these cases one eye only 
is affected ; and, although the ophthalmoscopic appearances are 
sometimes very slight, yet vision may be quite lost in a few- 
hours or days, atrophy of the nerve then rapidly setting in. 

Very many of the cases, however, do not go on to atrophy, 
but end in recovery of useful vision. 

Exposure to cold, especially if the skin be heated and per- 
spiring. 

* Ulrich, Archives of Ophthal., xviii, p. 65. 



THE OPTIC NERVE. 459 

Suppression of the Menstruation. — If during the menstrual 
period the flow be arrested by exposure to cold, wet feet, etc., 
acute optic neuritis with rapid blindness may come on. Spon- 
taneous amenorrhea, or even irregularity of menstruation, and 
the climacteric period are liable to have a similar but more 
chronic result. Nothing is definitely known with regard to 
the connection between the uterine and ocular disorder, but it 
is believed that the latter is due to " determination of blood " 
taking place to the base of the brain instead of to the uterus. 
In these cases the ophthalmoscopic appearances^ as well as the 
blindness, are apt to be extreme. Treatment here should be 
directed chiefly to restoring the normal uterine functions. 
Hot foot-baths and Heurteloup's leech to the temples are of 
use. 

Chlorosis. — Here optic neuritis often is present, due to the 
disordered state of the blood, and usually yields under the 
influence of iron. 

Syphilis. — The trunk of one or both optic nerves may be 
the seat of specific inflammation in connection either with con- 
genital or with acquired syphilis, but this primary specific 
optic neuritis is a relatively rare disease. In cases of acquired 
syphilis it makes its appearance in from six months to two 
years after the inoculation. 

The ophthalmoscopic appearances may be normal (retro- 
bulbar neuritis), or may present any grade of neuritis, ev^en to 
the most pronounced papillitis. In the latter case it would 
not be possible to say whether the papillitis is a primary one, 
or is due to a syphilitic gumma within the cranium. The 
inflammation often extends as far up as the chiasma. 

The treatment in these cases of specific papillitis must be 
active mercurialization. By this treatment, even if perception 
of light be lost for a period of not more than eight to fourteen 
days, hopes may be entertained of its complete or partial 
recover}'. 



46o DISEASES OF THE EYE. 

Cases of double optic neuritis of syphilitic origin have been 
observed in which complete recovery took place, the papilla 
returning- to its normal condition. But as a rule some 
optic atrophy, at the least, with slight concentric contraction 
of the field, results. The prognosis is all the better the 
sooner the optic neuritis follows upon the primary syphilitic 
affection. 

Rheumatism. — There is no doubt whatever but that the 
rheumatic diathesis is occasionally the cause of optic neuritis, 
although the fact is not unreservedly accepted by every 
author. Other manifestations of rheumatism are sometimes 
well marked, but may be slight ; e. ^., in a case which I saw, 
neuralgia of the face and head in damp weather, and even 
with a shower of rain, was the only other sign of rheumatism. 
One or both optic nerves may be attacked. 

Tlic ophthalmoscopic appearances often amount to extreme 
papillitis, but in many cases fall short of this. 

If the case come early under suitable treatment, the prog- 
nosis is fairly favorable ; but when the inflammation is of some 
standing consecutive optic atrophy must be feared. 

T/ie treatment consists of full doses of salicin, salicylate of 
sodium, iodid of potassium or of sodium, Turkish baths, and 
other recognized anti-rheumatic measures. 

Lead-poisoning. — In some cases of lead-poisoning, optic 
neuritis, not to be distinguished from that of primary cerebral 
affections, is found. Sometimes the ophthalmoscopic appear- 
ances are very slight, and, again, quite pronounced, the 
changes extending into the retina, and simulating the retinitis 
of Bright' s disease ; and in such cases renal disease is likely 
to have much to do with the causation of the retinitis. 
Indeed, there are those who, with good opportunities for 
forming a correct opinion, deny the existence of a specific 
lead neuritis, and hold that the neuritic affection in all such 
cases is to be referred to albuminuria, to effusion into the 



THE OPTIC NERVE. 461 

ventricles of the brain and subarachnoid space, or to suppres- 
sion of menstruation. Occasionally optic atrophy is the first 
ophthalmoscopic appearance seen ; but it is probably consecu- 
tive to retrobulbar neuritis, as shown by white striae (perivas- 
culitis) along the vessels. 

TJie vision is often much affected, and it is stated that 
sudden complete blindness in connection with an intercurrent 
attack of lead colic may appear and pass off again. Consecu- 
tive atrophy is liable to come on, and then vision may be 
seriously and permanently damaged. 

The diagnosis depends entireh' on the presence of the other 
well-known symptoms of lead-poisoning, the ophthalmoscopic 
appearances presenting nothing pathognomonic. 

The treatment is that for general lead-poisoning, or for the 
immediate cause of the neuritis. 

In peripheral neuritis optic neuritis is occasionally found. 

Multiple Sclerosis. — In these cases the inflammation is very 
ephemeral, and rapidly gives place to atrophy. Uhthoff 
states that it occurs in about 13 per cent, of the cases of this 
disease. 

Hereditary and Congenital Predisposition. — It has been 
observed that optic neuritis, without immediate cause, may 
attack several members of a family, and that the tendency to 
it may extend over several generations. It makes its appear- 
ance in these instances about the eighteenth or twentieth year 
of age, and confines itself almost exclusively to the males. 
The patients may be perfectly healthy in all other respects, 
but many of them suffer from other affections of the nervous 
system. Both eyes are affected, the defect of vision being a 
central amblyopia, from which recovery is rare ; but yet, 
although the ophthalmoscopic appearances gradually become 
those of atrophy, the peripheral portions of the field retain 
their functions. 

As to tlie treatment of these cases, due to hereditary and 



462 DISEASES OF THE EYE. 

congenital predisposition,* Mooren employs a seton in the 
back of the neck in the early periods, and, later on, nitrate 
of silver internally. Leber has found benefit from a mild 
course of mercurial inunction. 

Optic neuritis also occurs occasionally in fevers ; it has 
been observed in measles, scarlatina, typhoid, and malaria. 
It may follow influenza, causing contraction of the field of 
vision or central scotoma which usually disappear, but, on 
the other hand, it may lead to optic atrophy. 

The two following diseases — chronic retrobulbar neuritis 
or central amblyopia, and optic neuritis with persistent drop- 
ping from the nostril — must be treated of separately, owing to 
the well-defined etiology of the one and the peculiar symptoms 
of the other. 

Chronic Retrobulbar Neuritis, or Central Amblyopia 
(Toxic Amblyopia). — Until within recent years it was not 
clearly known whether these two terms should be applied to 
one and the same disease or whether we had to deal here with 
two distinct processes. There is a class of cases which were 
admittedly due to an inflammatory process in the trunk of the 
nerve, the causes and symptoms of which were very similar to 
those of central amblyopia ; while there was strong presump- 
tive evidence that the latter affection, often known as toxic 
amblyopia, was due to a retrobulbar inflammation ; yet direct 
proof of the fact was wanting. But there is now no doubt 
that we have here to deal with only one disease. f 

Symptoms. — The affection of vision often comes on rather 
rapidly. The patient may complain of a glimmering mist 

* Mooren, Ophthal. Bericht, 1867, p. 305, and 1874, p. 87; and Fiinf 
Lustre7i Ophthal. Wirksamkeit, 1882, p. 248. Norris, Trans. Ainer. Ophthal. 
Soc, 1884, p. 662. 

f Samelsohn, A. von Graefe'' s Archiv, xxviii, pt. i, p. I. Nettleship and 
Walter Edmunds, Trajis. Ophthal. Soc, Vol. i, p. 124. Uhthoff, voji Graefe's 
Archivy xxxii, p. 4. Sachs, Archives of Ophthal., xviii, p. 133. 



THE OPTIC NERVE. 463" 

which covers all objects, especially in a bright Hght, and the 
acuteness of vision is reduced. The patient generally states 
he can see better in the dusk than in bright light. At the 
commencement there is no defect in the field of vision, but 
simply a general dimness of vision. At a somewhat later 
stage, examination of the field discovers no defect for a white 
object : yet, if a small pale green object be employed, it will 
generally be ascertained that, at a region close to the point of 
fixation, the color is not recognized, but seems gray or white ; 
pink may seem blue, and red may appear brown or black ; 
while in other parts of the field the colors are recognized up 
to their normal boundaries. This is a central color-scotoma. 
As the disease advances, a white object will be but indistinctly 
seen in the scotoma ; and in some rare cases all power of 
perception within its area may be lost, even the flame of a 
candle not being recognized. Hence the name central ambly- 
opia. The scotoma is usually oval in shape, its long axis 
horizontal, and extends from the fixation-point toward the 
blind-spot of Mariotte (paracentric scotoma), but occasionally 
it is of much larger dimensions, and sometimes surrounds the 
fixation -point (pericentric scotoma). 

Even when the scotoma is very pronounced it remains 
" negative " — /. e\, it is not observed by the patient as a dark 
spot in the field, as is a scotoma due to disease in the outer 
retinal layers. The affection is almost always binocular, and 
as a rule there is but little difference between the vision of the 
two eyes. 

T/ie progress of the disease is slow, occupying weeks or 
months. Restoration of normal vision usually takes place if 
the defect of vision, although of extreme degree, be not of old 
standing. In the latter case, while recovery of central vision 
cannot be expected, the functions in the periphery of the field 
are usually maintained ; and, consequently, these people, 



464 DISEASES OF THE EYE. 

although incapacitated from reading, writing, and other fine 
work, do not lose their power of guiding themselves. 

Causes. — With but few exceptions the subjects of this disease 
are men, probably because their habits and modes of life ex- 
pose them, more than women, to the influences which produce 
it. These are exposure to cold and wet ; cold blasts on the 
body, especially the heated face (Samelsohn) ; but the most 
common cause is excess in the use of alcohol, or of tobacco 
(toxic amblyopia), or of both. I think the kind of alcoholic 
indulgence most likely to develop the disease is the frequent 
drinking of small doses of the stimulant. The individual who 
often gets thoroughly intoxicated, and between times drinks but 
little, is less liable to central amblyopia that he who, although 
never incapable of transacting his business, takes many half- 
glasses of whisky or brandy during the day. Dyspepsia and 
loss of appetite are constantly present in these cases. Other 
signs of chronic alcoholism need not be present, but one often 
sees trembling of the hand and head, sleeplessness, and even 
deHrium tremens. The kind of tobacco most likely, when 
used in excess, to give rise to central amblyopia is shag or 
twist. Other kinds of pipe-tobacco and cigars may cause it, 
but I have not known of a case due to cigarette-smoking. 

Excess in alcohol is usually combined with excessive smok- 
ing, but cases of pure alcohol-amblyopia certainly do occur — 
although some English authors deny it — as well as pure 
tobacco-amblyopia. The most common age for tobacco-am- 
blyopia is from thirty-five to fifty — a time of life when men do 
well to give up, or to very much reduce, their use of tobacco, 
as well as of alcohol. 

Central amblyopia has also been observed in diabetes, in 
poisoning from bisulphid of carbon,* so largely used in the 

* Trans. Ophth. Soc, Vol. v, p. I49. 



THE OPTIC NERVE. 465 

manufacture of india-rubber, from dinitrobenzol,"^ used for ex- 
plosives, and in iodoform-poisoning.t 

Retrobulbar neuritis very occasionally attends disseminated 
sclerosis, with atrophy of the temporal side of the papilla ; but 
yet central scotoma is not always present here. 

Tlie oplitJialmoscopic appearances in the beginning are either 
quite normal or there is slight hyperemia of the papilla and 
retinal vessels ; or, in addition, there may be slight indistinct- 
ness of the margins of the papilla, and sometimes white striae 
along the vessels, especially before they leave the papilla. All 
the primary appearances, if any be present, soon pass away, 
and give place to a grayish whiteness of the temporal side of 
the papilla, while the nasal portion remains of normal appear- 
ance, as do also the vessels. At a very advanced stage, in 
some cases, the whole papilla presents the appearance of white 
atrophy. 

TJie patlwlogic cJianges observed by Samelsohn, Nettleship, 
and Walter Edmunds, and Uhthoff in the optic nerve, consist 
of an interstitial neuritis at its axis, commencing so high up as 
the optic foramen, and leading to proliferation of connective 
tissue and to secondary descending atrophy of a certain bundle 
of nerve-fibers. These are, doubtless, the fibers which supply 
the region of the macula lutea. The changes are analogous 
to those which take place in the liver and brain as the result 
of chronic alcoholism. 

Treatment consists, above all, in total abstinence from the 
poison in question. The patients are generally ready to 
promise this, but they often do not act up to their intentions. 
When they do so, improvement rapidly takes place in most 
cases which are not too far gone, without any other treatment ; 



*S. Snell, Brit. Med. Jotirn., March 3, 1894. 

I P. Smith, Ophthal. Rev., 1893, p. loi ; and Vakide, ^<?57//^ c/' Ophthal. 
1893, p. 231. 
39 



466 DISEASES OF THE EYE. 

but the cure may be promoted by the use of iodid of potas- 
sium in large doses, Heurteloup's artificial leech or dry cup- 
ping to the temples, hot foot-baths, and Turkish baths. 
Strychnin hypodermically, -^-^y of a grain daily, in the temple is 
often of use, and phosphorus and strychnin may be given in- 
ternally. Whatever remedy be used internally, care should be 
taken that it does not produce or increase dyspepsia ; and it 
may be necessary to restrict the internal medicine for a time, 
or altogether, to a stomachic tonic. Sleeplessness should be 
combated with chloral and bromid of potassium. Treatment 
may have to be continued for some weeks before a cure can 
be noted. 

Optic Neuritis Associated with Persistent Dropping of 
Watery Fluid from the Nostril. — Nettleship * (one case), 
Priestley Smith f (two cases), Leber :|: (one case), and Emrys 
Jones § (one case) have placed on record five well-observed 
cases of this remarkable disorder, and three others have been 
observed by EUiotson, Baxter, and Paget. These patients 
suffered from a persistent watery discharge from the nose 
(usually the left nostril), with more or less sev^ere cerebral 
symptoms — violent headache, epileptic attacks, vomiting, stu- 
pidity, sleepiness, unconsciousness, delirium, weakness of the 
lower extremities, and a high degree of amblyopia, or even 
blindness, of both eyes, due to papillitis followed by atrophy. 
In Leber's case, moreover, there was loss of smell, and in 
Nettleship's case palpitation of the heart and prominence of 
the eyes. The fluid which ran from the nostril was, accord- 
ing to Leber, identical in its analysis with that of the cerebro- 
spinal fluid, while Nettleship and Priestley Smith found it to 

* Ophthal. Rev., 1883, p. I. 

^ Ibid., 1883, p. 4. 

\A. V071 Graefe's ArcJiiv, xxix, pt. i, p. 271. 

?l Meeting British Med. Assoc, Dublin, 1887. 



THE OPTIC NERVE. 467 

differ somewhat from that fluid. When, in P. Smith's case, 
it occasionally ceased to flow, the cerebral symptoms were 
brought on or increased in violence. Leber's case was one of 
internal hydrocephalus, and he regards the fluid as coming 
from the third ventricle through a small opening in the ethmoid 
bone ; or the fluid possibly passed from the subdural space 
along the lymph-spaces, which, according to Axel Key and 
Retzius, surround the olfactory nerves. But Priestley Smith 
and Nettleship considered the fluid as simply nasal, and due 
to the presence of small polypi, and did not try to account for 
its occurrence in connection with the cerebral and ocular 
symptoms. The first of these two views is probably the 
correct one. 

Tlie prognosis for vision is bad, while the cerebral affection 
threatens even the life of the patient. 

Treatment, which should be in conformity with the head 
symptoms, has not proved of use. 

Atrophy of the Optic Nerve. — This disease may be sec- 
ondary to some other optic nerve or retinal affection, or it 
may be a primary disease. TJie vision is seriously affected, 
and complete bhndness is the usual result. With the opJithal- 
moseope the optic papilla is seen to have lost its delicate pink 
color, and to have become white or grayish, while it is often 
cupped, and the vessels are apt to be diminished in caliber. 

Secondary atrophy of the optic nerve may result : 

I. From Optic Neuritis. — The ophthalmoscopic appearances 
consist in a white or grayish-white color of the papilla, with 
very diminished retinal vessels ; and along both sides of the 
vessels, far into the retina, are seen white lines, which some- 
times even obscure the vessels, and which are due to hyper- 
trophy of their coats. The diminution in caliber of the vessel 
is a sign of neuritic atrophy, but is not always present, and 
is, moreover, found with other forms of atrophy. Other signs 
of this form, also not constant, are : a certain opacity of the 



468 DISEASES OF THE EYE. 

papilla, and that the lamina cribrosa is not generally visible, 
owing to development of connective tissue at the papilla. It 
is evidently not always possible to recognize any given case 
as of neuritic origin. This form of atrophy is commonly called 
consecutive atrophy. 

Symptoms. — Central vision is lowered, and, as a rule, the 
field of vision becomes contracted, usually more at the nasal 
side. Subsequently the temporal side of the field becomes 
contracted, and, finally, a small, eccentric portion of the field to 
the temporal side may be all that remains, or even this may 
disappear, and absolute amaurosis result. The color-vision is 
always much affected. The light-sense is affected, so that there 
is diminished sensibility for differences of illumination ; while, 
in choroidoretinal diseases, there is defect in the quantitative 
perception of light, the minimum quantity being larger than 
normal* 

2. From Pressure. — This may be brought about by a tumor 
anywhere in the course of the nerve, by inflammatory exuda- 
tions, by a splinter of bone in cases of fracture of the skull, 
and, also, by pressure upon the chiasma by the floor of the 
distended third ventricle in cases of internal hydrocephalus. 

3. From Embolism of the Central Artery of the Retina. — In 
these cases the contraction of the vessels is usually extreme. 

4. From Syphilitic Retinitis, Retinitis Pigmentosa, and Cho- 
roidoretinitis. — The vessels here are much attenuated, and 
the altered color of the optic disc is a dull yellow rather than 
white or gray. 

Primary optic atrophy is often fonnd associated zvith disease 
of the spinal cord {spinal amaurosis^, especially locomotor 
ataxia. Optic atrophy is often an early symptom in the latter 
disease ; but, again, it may not come on until the affection of 
the gait is well pronounced, while in other cases it is never 

* Bjerrum, i-on Graefe's Arc/iiv, xxx, pt. ii, p. 201. 



I 



THE OPTIC NERVE. 469 

present at all. It is a remarkable and important fact, first 
pointed out by Benedikt, of Vienna, that there is an antago- 
nism between atrophy of the optic disc and the other symp- 
toms of tabes dorsalis. It is rare for a tabetic patient, in whom 
optic atrophy comes on in an early stage of his disease, to 
become ataxic ; and frequently, in these cases, when the 
bhndness has advanced, the pains, too, become less severe. 
But if amaurosis does not come on until the ataxia is well 
developed, no improvement in the latter is likely to be noted. 

Atroph}^ is found more rarely with insular sclerosis and 
lateral sclerosis of the spinal cord ; and in general paralysis 
of the insane, although spinal disease is not always present, 
atrophy of the papilla frequently occurs. 

It is probable that the disease commences at the papilla in 
spinal cases. The ophthalmoscope displays a paper}'-white or 
bluish-white papilla, which in advanced stages often becomes 
cupped. The retinal arteries are usually extremely reduced in 
caliber, and the veins, too, maybe small ; but, again, the retinal 
vessels may differ but little, or not at all, from the normal. 

Symptoms. — Central vision is affected at an early stage in the 
•disease, and eccentric contraction of the field usually appears 
at the same time. The contraction may be concentric, or it 
may be more marked in one direction than another, and opinion 
is divided as to the direction commonly first involved. This 
concentric contraction advances gradually toward the center of 
the field from every side, until it finally engulfs the fixation- 
point. 

Occasionally the affection begins as a central scotoma, ac- 
companied by eccentric defects of the field. Color-blindness 
is an almost constant symptom. As a rule, absolute blindness 
is brought about in the course of a year or two. 

Primary optic atrophy, of the progressive form just described, 
ma)" occur as a purely local disease, without an}' other defect in 



470 DISEASES OF THE EYE. 

the system. The prognosis for the sight in such cases is as 
bad as in spinal cases. 

Treatment. — In neuritic atrophy, so long as there are still 
signs of active inflammation, antiphlogistic measures — Heurte- 
loup's leech to the temple, hot foot-baths, rest of body and 
mind, dark room, iodid of potassium, and, especially, mercury 
internally, when otherwise admissible — are to be adopted. At a 
later period hypodermic injections of strychnin, -^-^ of a grain, 
increased gradually to ^V ^^ tV °^ ^ grain once a day, and 
galvanism may be tried. Hypodermic injections of antipyrin, 
about 7^ grains every second day, have been given by 
Valude with some benefit in these cases.* 

In spinal amaurosis, and in optic atrophy occurring as a 
local disease, strychnin hypodermically and the galvanic current 
sometimes improve vision for a time. Phosphorus internally 
may be given. 

The treatment for optic atrophy, due to causes 2, 3, and 
4, is to be directed to the primary disease. 

The prognosis is very serious; for, although every thera- 
peutic measure may have been employed, amaurosis is the 
ultimate result as a rule. 

Tumors of the Optic Nerve. — Ninety-four cases of this 
rare affection have been recorded. f It occurs at all ages, but 
75 per cent, of the patients are under twenty years of age. The 
tumors are generally situated about the center of the nerve, 
and do not reach to the ocular end. The symptoms are : 
slow and gradually-increasing protrusion of the eyeball for- 
ward and outward, with retention of its motion, and without 
displacement of its center of rotation. The tumor is sometimes 
soft, so that the eyeball can, as it were, be pushed back into it ; 

* Annates d' Oculist., 1893, p. 161 ; and 1894, p. 68. 
f Braunschweig, von Gracfe" s Airhiv, xxxix, pt. iv, p. I. 



THE OPTIC NERVE. 471 

but, in an\- case, pressure does not cause pain. The sight is 
usually very defective, or quite lost, through optic neuritis or 
atrophy. The pupil reacts consensually. The tumor may be 
felt b}' palpation. 

These tumors are either myxosarcomata, or, less frequently, 
endotheliomata, and are usually encapsuled by the sheath of 
the nerve. The\- are benign, in the sense that they do not 
lead to glandular enlargements or to metastases ; but in rare 
cases they extend into the cranial cavity. 

Treatment. — It is sometimes possible to remove such a 
tumor, and }'et to preserve the eyeball, by dislocating the 
latter during the operation. As a rule, it is necessary to 
enucleate the e}-eball in order to reach the tumor ; and if the 
crrowth has involved the surroundincr orbital tissues these, 
too, must betaken away. Braunschweig, in some cases, made 
a flap containing a wedge-shaped piece of the outer wall of the 
orbit, in order to facilitate access to the back of the orbital 
cavit}'. 

Hyaline, or colloid, outgrowths from the optic papilla are 
occasionally met with. They present the appearance of bluish- 
gray, mulberry-Hke nodules. According to Iwanoff^ they 
orioinate in the lamina vitra of the choroid at the margin of 
the papilla, or within the area of the papilla ; for the lamina 
vitra is often prolonged into the papilla, and takes part in the 
formation of the lamina cribrosa. But Gurwitsch f disputes 
this view, and states that these growths spring from the coats 
of the vessels in the optic papilla. These outgrowths do not 
always cause a defect of sight, and rarely cause serious bhnd- 
ness. It is often found that a blow upon the e}'e has been re- 
ceived some time previously, and it is probable that such a 
trauma may ha\"e to do with the growth by rupturing the \-ery 
brittle lamina vitra. 

Treatment is of no avail. 

"^ IClin. Monatsbl. f. Augenheilk., vi, p. 425. 
f Centi-albl. f. Augenheilk.., August, 1 89 1. 



472 DISEASES OF THE EYE. 

Injuries of the Optic Nerve. — In addition to those injuries 
which result from direct violence with sharp instruments, etc., 
entering the orbit, the optic nerve may be injured in falls on 
the head. Fractures of the base of the skull frequently involve 
injury to the optic nerve. But even where no fracture occurs, 
blindness with atrophy of the optic nerve may come on, usually 
only in one eye, and in these cases concussion of the nerve at 
its passage through the optic foramen, or an extravasation of 
blood in the sheath of the nerve, is probably the direct cause 
of the atrophy. 

Hemorrhages from the stomach, bowels, or uterus 
are capable of giving rise to serious and incurable blindness. 

Blindness during or immediately after a severe hemorrhage 
is probably due to insufficient blood-supply to the nerve-centers 
and retina, accompanying general exhaustion of the system. 
For such cases the prognosis is favorable. 

But there is another class of cases of very much more 
serious import. In these the defect of vision does not come 
on for from two to fourteen days after the hemorrhage, when 
the general system is recovering. Even comparatively slight 
hemorrhages, which caused no marked anemia, are said to have 
been followed by blindness. The connection between the loss 
of blood and of sight in these cases is not yet clearly made out. 
Leber inclines to the belief that the blindness here is due to an 
extravasation of blood at the base of the skull and into the 
sheath of the optic nerve ; but even then the relationship be- 
tween this and the stomachic or uterine hemorrhage is not 
made clearer. Papillitis has been several times noted with the 
ophthalmoscope in these cases ; and this circumstance makes 
it probable that neuritis is the immediate cause of blindness, 
even in those cases which show no ophthalmoscopic sign of it, 
and hydremia may be presumed to be the influence which 
calls forth the neuritis. 

TJie defect of vision may be but slight, or it may amount to 
absolute amaurosis. Both eyes are usually affected in equal 



THE OPTIC NERVE. 473 

degree. But cases have been observed in which one eye was 
completely amaurotic, while the vision of the other eye was 
quite normal ; and one such case is sufficient to prove that the 
lesion is peripheral — in fact, that it lies in each instance on the 
distal side of the optic chiasma. The field of vision is frequently 
contracted, either concentrically or segmentally > and even 
when central vision recovers, the field may remain contracted. 
The ophthalmoscopic appearances which are present immedi- 
ately on the occurrence of the blindness have not as yet been 
observed. A few weeks later they have been found to be 
different in different cases. They have been found at this 
period normal ; or presenting slight paleness of the papilla and 
contraction of the arteries ; or there was marked paleness of 
the papilla, and the arteries were extremely contracted, with 
shght distention of the veins ; or paleness of the papilla was 
present, but its margins were indistinct, and the surrounding 
retina somewhat swollen, while the retinal vessels were normal. 

Small hemorrhages have repeatedly been seen in the neigh- 
borhood of the papilla. At later periods well-marked optic 

atrophy is frequently observed. 

Prognosis. — If in the beginning the defect of vision be 

merely amblyopia, and not complete blindness, hopes may be 

entertained of marked improvement or of complete recovery. 

But Mooren has seen slight amblyopia pass into permanent 

amaurosis. 

Hemorrhages from the stomach are those which are followed 

by the most complete and permanent blindness, while uterine 

hemorrhages are more commonly .follow^ed by less serious 

degrees of blindness. 

The treatment must consist of internal remedies calculated 

to correct the general anemia, such as iron, beef-tea and meat 

extracts, wine, etc. Strychnin hypodermically, to stimulate 

the nerve, may be employed. 

Glycosuric Amblyopia. — In addition to the retinal affec- 
40 



474 DISEASES OF THE EYE. 

tions dependent upon diabetes, we recognize the occasional 
occurrence in that disease of defects of vision which are referred 
to disorder of the optic nerve, and which are not always ac- 
companied by ophthalmoscopic changes. These defects of 
vision are found in the form of: i. Central amblyopia (see p. 
464), or, in slighter cases, as amblyopia without central 
scotoma. Occasionally, higher degrees of amblyopia with 
concentric contraction of the field of vision, and yet negative 
ophthalmoscopic appearances, are present. 2. Atrophy of the 
optic nerve. This may appear in the usual form as progres- 
sive blindness, with concentric contraction of the field of vision ; 
or it may come on after the slighter form of amblyopia has 
existed for some time. 3. Hemianopia and color-blindness 
(Samelsohn). 

It is probable (Leber) that these apparently different kinds 
of blindness depend upon similar pathologic processes, and 
merely indicate degrees of the latter. In what these pro- 
cesses consist is still unknown ; but the tendency to hemor- 
rhages in the retina in diabetes makes it likely that hemorrhages 
in the optic nerve are sometimes the source of the amblyopia 
in question ; while in the cases with central scotoma it is no 
doubt due to retrobulbar neuritis similar to that produced by 
tobacco, etc. 

Amblyopia is sometimes the only symptom of diabetes ; and 
consequently, as Leber points out, it is of the utmost import- 
ance to examine the urine for sugar in every case of amblyopia 
where the ophthalmoscopic appearances are negative, or where 
the only abnormality is atrophy of the optic papilla. 

TJie treatment indicated is solely that for the general disease, 
and the prognosis for vision depends upon the amenability of 
the latter to treatment and upon the extent to which organic 
changes in the optic nerve have gone. Hirschberg inclines to 
the view that diabetic amblyopia constitutes a serious symptom 
for the life of the patient. 



CHAPTER XVII. 

Pai't I. — Ocular Diseases and Symptoms liable to accom- 
PAXY Focal Disease of the Brain. 

Part II. — Ocular Diseases axd Sympto:\is liable to accom- 
pany Diffuse Organic Disease of the Brain. 

Fart III — Ocular Diseases and Symptoms liable to accom- 
pany Diseases and Injuries of the Spinal Cord. 

Fa7't IV. — Xeryous Amblyopia, or Asthenopia. 

Fa?'t V. — Various Forms of Amblyopia. 

Part I. 

OCULAR DISEASES AND SYMPTOMS LIABLE 

TO ACCOMPANY FOCAL DISEASE OF 

THE BRAIN. 

Hemianopia (/Ja:, lialf ; ay, priv.; ioib, the eye). — This 
term implies a loss of sight in one-half of the field of vision, 
usually of each eye, consequent upon a lesion at the center 
of vision, at the chiasma, or at some point in the course of 
the visual fibers between these two places. It is not used for 
cases in which one-half of the field is lost, owing to disease 
within the eye itself. 

The line di\iding the seeing from the blind half passes 
vertically down the center of the field, as in figure 122."^ 
Sometimes this line lies a little to one side of the center of the 
field, so as to admit of the latter being included in the seeing 
part, as in figure 123 ; and sometimes, although in other 
respects the dividing line lies in the center of the field, the 
fixation-point is circum\'ented b}- it, so as to leave that point 

* Figs. 122, 123, 124, 125, and 126 are diagrammatic representations of the 
left field of vision. 

475 



476 



DISEASES OF THE EYE. 



free, as in figure 124 ; and probably this is the most common 
arrangement. This subject will be further discussed on page 
48 1 . Again, although rarely, the dividing line may have an 
oblique direction, as in figure 125. It is probable that such a 




Fig. 122. 



Fig. 123. 



Fig. 124. 



field as figure 125 is due to some peculiar arrangement. 
Furthermore, cases occur which are properly regarded as 
hemianopia, and yet in which only a sector of one side of the field 
is wanting, as in figure 126. Figures 122, 123, 124, and 125 
would be called complete hemianopia, while figure 126 would 
be termed incomplete or partial hemianopia. Finally, if all 





Fig. 125. 



Fig. 126. 



three visual perceptions be lost, the hemianopia is called, in 
the decussation of the nerve-fibers in the individual case, 
absolute ; but if only one (color) or two (color and form) be 
wanting in the defective part of the field it is termed relative 
hemianopia. The vast majority of cases of hemianopia are 
absolute. 

Homonymous hemianopia is the most frequent form. In 
it the corresponding half — the right half or the left half — of 



FOCAL BRAIN DISEASE. 477 

the field of each eye is wanting, as in figure 127, in which the 
left side of the fields, from the patient's point of view, is blind, 
implying a loss of function in the right half of each retina. 

Temporal hemianopia is loss of vision in the outer side of 
each field, in consequence of loss of power in the median half 




Left Field. -t* IG. I27. Right Field. 



of each retina (Fig. 128). It is by no means so common as 
the homonymous form. 

Superior or inferior hemianopia, also called altitudinal 
hemianopia, in which the upper or lower half of the field is 
blind, is very rare ; and it is doubtful whether nasal hemian- 
opia has really been observed, although it has been described. 
In the latter the inner side of the field of one eye only is 





Left Field. FiG. I28. Right Field. 

lost, owing to defective function of the temporal side of the 
retina. 

It will be convenient here to set forth the prevailing views 
as to 

The Arrangement of the Cortical Visual Centers, their Rela- 
tions to the Retina, and the Course of the Optic Fibers betzueen 
these two points. — Pathologic anatomy leaves little doubt but 



478 DISEASES OF THE EYE. 

that in man the visual center is situated on the mesial surface 
of the occipital lobe, rather than in the angular gyrus or else- 
where ; and the evidence goes to show that the absolute 
optic center chiefly occupies the cortex of the cuneus and of 
the superior occipitotemporal convolution. 

Henschen,* as the result of clinico-pathologic investiga- 
tions, believes it to be situated in the middle part of the 
calcarine fissure, which lies between these structures ; and that 
the upper, or cuneic lip represents the homonymous dorsal 
retinal quadrants ; while the lower, or lingual lip represents 
the homonymous ventral quadrants of the retina. Vialet,t on 
the other hand, thinks that the visual center embraces all the 
mesial surface of the occipital lobe included between the occipito- 
parietal fissure and the lower border of the third occipital 
convolution, and that it extends above and behind as far 
as the free border of the hemisphere. The calcarine fissure 
he, however, also regards as of great importance J ; and 
I think, indeed, he rather proves than disproves Henschen's 
view of its middle third being the actual cortical center for 
vision. 

It is universally recognized that the nerve-fibers from the 
homonymous half of each retina — c. g., from the temporal half 
of the right and from the median half of the left retina, pass 
wholly through the corresponding optic tract, — in this case 
the right tract, — to the corresponding cortical center for 
vision (Fig. 129). 



* Klinische ttnd Anat. Beitrdge ziir Pathol, des Gehinis, Upsala, 1890-92. 

f Vialet, " Les Centres Cerebraux de la Vision," Paris, 1893. 

X One of the most important cases which has been published in connection with 
this question is that of Dejerine and Vialet (Societe de Biologie, Paris, Decem- 
ber, 1893), in which both eyes became suddenly blind, without loss of conscious- 
ness or other symptoms. The patient lived for a long time, and after death from 
pneumonia the postmortem showed lesions of the structures bordering the cal- 
carine fissure on both sides. 



FOCAL BRAIN DISEASE. 
LF. KE 



479 




PH. MP 

Fig. 129. 

EXPLANATION OF FIGURE 129. 

Fig. 129. — Diagram of Course of Optic Fibers, with the Cortical Centers and 

Relations to Fields of Vision, illustrating one theory of the Macular Supply ; 

according to which the macula is supplied on the same plan as the rest of the 

retina — i. e., each side of it from the corresponding side of the brain. 

R.F. Right field of vision. L.F. Left field of vision. R.E. Right eye 
(retina). L.E. Left eye (retina). m.l. and m.l. Macula lutea. O.N. and 



48o DISEASES OF THE EYE. 

O.N. Optic nerves. Ch. Chiasma. Tr. and Tr. Optic tracts. R.C.C. and 
L.C.C. Right and left cortical centers. M. and M. Macular fibers. P. and 
P. Peripheral fibers. 

1. Lesion of right cortical center = left homonymous hemianopia, the line of 
demarcation passing around the left side of the fixation-point in cases of embolism 
and thrombosis, but through the fixation-point in cases of hemorrhage (see p. 481). 

2. Lesion of the right optic tract = left hemianopia, the line of demarcation 
passing through the fixation-point. 

3. Lesion of the chiasma =: bitemporal hemianopia, the line of demarcation 
passing through the fixation-point. 

4. Lesion involving fasciculus lateralis only to right eye, causing nasal 
hemianopia in the right field. 

Diagram 129 also illustrates the fact that, as regards its relation to the optic 
tracts, the field of each eye is divided unequally, and not in halves; e.g., the 
right tract governs about one-third of the field of the right eye, while the other 
two-thirds is governed by the left optic tract. 

A case published by Hun,* in which the left lower quadrant 
in each field was blind, and where the autopsy showed a 
lesion (atrophy) strictly limited to the lower half of the right 
cuneus, renders it probable that there is in man a correlation 
between parts of the retina and of the occipital lobe, as Munk 
had already proved to be the case in dogs, and that the optic 
fibers from the right lower quadrant of each retina terminate in 
the adjacent part of the right superior occipitotemporal con- 
volution, the left halves of the retina and left optic centers 
being, of course, similarly correlated. If this view be correct, 
as seems probable from Henschen's investigations, it is evident 
that altitudinal hemianopia can hardly occur as the result of 
a central lesion, as nothing short of disease confined to the 
lower half of each cuneus would produce it. 

It is now generally believed that relative hemianopia — e.g., 
color hemianopia alone — is the result of a lesion of less in- 
tensity than that which causes absolute hemianopia. Mackay f 
points out that cases of apparently pure hemiachromatopsia 



^ A inerican Journal 0/ ihe Med. 5r/<?«(r^J, January, 1887. 
I British Med. Journ. , November lo, 1888. 



FOCAL BRAIN DISEASE. 481 

may, with careful tests, show some diminution of the form- 
sense in the half fields which are defective for color-sensations. 
Non-cortical lesions, even at the chiasma,* may also give rise 
to hemiachromatopsia. Thus it would seem that the color- 
sense is more easily affected by disease than the form or light 
senses, and that, too, irrespective of the position of the lesion 
in the visual path. 

It is now generally conceded that the macula lutea is 
specially represented in the cortical center. But there are at 
least two very distinct views as to the arrangement of these 
macular centers, and as to the course of the macular fibers. 
These different views have been called into existence by the 
desire to explain the fact that in hemianopia the line of de- 
marcation sometimes passes through the fixation-point in the 
field and sometimes leaves it in the seeing half. It seems to 
me that neither of these theories is quite satisfactory, and I 
regret that I cannot offer one that is more so. 

According to one theory, illustrated by figure 129, the 
macular region of the retina is invariably supplied on the 
same plan as the rest of the retina — /. ^., each side of it from 
the corresponding side of the brain. In order, then, to ex- 
plain why it is that in some cortical lesions the line of demar- 
cation passes through the fixation-point in the field, while in 
others it deviates toward the blind side, the supporters of this 
view state that the cortical center for the macular region is 
more richly supplied with blood-vessels than the rest of the 
visual center ; as is the macula lutea itself in relation to the 
rest of the retina. Hence, when the lesion is an embolism, 
or thrombosis, of the vessels supplying that part of the brain, 
this special region, by reason of abundant anastomoses, pre- 
serves its functions, and then fields as in figure 127 are pro- 
duced. But if the lesion be a hemorrhage, the macular region 

^ Hill Griffith, Medical Chronicle, January, 1887. 



482 DISEASES OF THE EYE. 

of the cortex would be apt to be involved in the lesion with 
the rest of the visual center, and loss of function in the cor- 
responding half of the macula lutea, with the line of demarca- 
tion passing through the fixation-point, results. 

According to the other theory, the whole of the macular 
region — and in some instances even more than this — of each 
retina being innervated from each hemisphere, there is an 
overlapping, as it is called, of nervous supply to these retinal 
regions. Consequently, if there be a lesion at the center for 
vision in one occipital lobe, the center for vision in the other 
occipital lobe being sound, the functions of the whole of each 
macula — or even of more than this — of the defective side of 
each retina will be preserved. Cases where, occasionally, in 
cortical lesions, the line of demarcation in the field does go 
through the fixation-point, would be accounted for under this 
theory by an individual variation in the supply of the maculae, 
which in these instances would be similar to that of the re- 
mainder of the retinae. 

But any such theory, to be satisfactory, must be capable of 
explaining the phenomenon in question, not only when the 
lesion is in the cortex, but also when the hemianopia is 
caused by a lesion in the tract or chiasma. Yet an examina- 
tion of figure 129 will show that, according to the theory it 
represents, in lesions of the tract (2), or of the chiasma (3), 
the line of demarcation would pass through the fixation-point. 
And, according to the other theory, a lesion either at the tract 
or at the chiasma would always cause the dividing line to cir- 
cumvent the fixation-point. It happens, however, that with 
lesions at either of these situations the dividing line sometimes 
passes through the fixation-point and sometimes to one side 
of it. Consequently, I do not think we have yet solved the 
problem of the nervous supply of the macula lutea. 

Some ophthalmologists hold that the line of demarcation 
always passes through the fixation-point, and that it is merely 



FOCAL BRAIX DISEASE. 483 

imperfect fixation on the part of the patient which makes it 
seem to pass around it. This I believe to be an erroneous 
view ; but there are, no doubt, cases in which it is difficult to 
determine the question, and where the line of demarcation 
approaches so close to the fixation-point that it comes to be a 
matter of degree. 

TJie localization of tlic lesion in cases of hemianopia is a 
subject of interest, and, in view of the advances made within 
recent years in cerebral surger}*, it is of great practical im- 
portance. 

Lesions of the center of the chiasnia, injuring the crossed 
fibers, produce as their characteristic symptom bitemporal 
hemianopia, which ma}- be relative at first, beginning, for 
instance, as a hemiachromatopsia, but later on becoming 
absolute. In some cases (basal meningitis, periostitis, hyper- 
ostosis) the diseased process comes to a standstill, and the 
bitemporal hemianopia remains. But the disease generally 
extends to the uncrossed fibers, ultimately causing complete 
blindness. Even when the disease is non-progressive, central 
vision is impaired ; whereas in homon}-mous hemianopia it 
is not always affected. Optic atrophy, often commencing on 
the inner side of the papilla, is nearly always present at some 
period of the disease. Syphilitic gummata may cause transient 
recurrent attacks of bitemporal hemianopia. 

In altitudinal hemianopia the lesion must also, as a rule, 
be at the chiasma, encroaching on it from above or below. 
Symmetric cortical lesions might, and optic neuritis some- 
times does, produce it. 

In nasal hemianopia, too, the lesion must be at the 
chiasma, and must be so situated in its outer angle as to 
involve only the fasciculus lateralis of the affected eye. The 
occurrence of binocular nasal hemianopia is evidently almost 
impossible, implying, as it does, symmetric lesion of the 
fasciculus lateralis of each tract. Accordine to Henschen, 



484 DISEASES OF THE EYE. 

a tumor in the external angle of the chiasma is apt to affect 
the crossed fibers as well as the uncrossed, and to produce a 
form of bilateral homonymous hemianopia. Other symptoms 
which may be present in lesions of the chiasma are anosmia, 
paralysis of orbital nerves, and anesthesia of the conjunctiva 
and cornea. The causes are : fractures of the body of the 
sphenoid, cysts, tubercle, tumors, exostoses, distention of the 
infundibulum of the third ventricle, and, most frequently, 
tumors of the pituitary body. In the latter case proptosis, 
discharge of fluid from the nostril, and diabetes may be present. 

Bitemporal hemianopia is a very common and early symp- 
tom in acromegalia, a disease characterized by great hyper- 
trophy of the face and extremities, associated with enlargement 
of the pituitary body, and other conditions which are not so 
constant. 

In homonymous hemianopia, the commonest form of the 
symptom, localization of the lesion is a more difficult matter 
than in any of the other forms ; for here the disease cannot be 
situated at the chiasma, but may be in the optic tract, or in 
the visual center, or anywhere in the lengthened course of the 
fibers which connect these two parts. 

Can we distinguish a complete and absolute hemianopia, 
due to a lesion confined to the occipital lobe, from a similar 
defect in the field, due to a lesion in the optic radiations, 
internal capsule, pulvinar, or optic tract? We may conclude 
that the hemianopia depends upon an occipital lesion, if it 
be unaccompanied by hemiplegia, motor aphasia, or paralysis 
of cerebral nerves, as direct symptoms ; but be it remembered 
that one and all of these are liable to accompany lesions of the 
occipital lobe as distant * symptoms. 

* I suggest the term " distant symptom " in preference to those in common 
use ; namely, " indirect symptom " and " pressure symptom." ^Ye cannot assume 
that these symptoms are less the direct result of the lesion than any of the others 
which are present ; and, in many instances at least, it is certain that they cannot 



FOCAL BRAIN DISEASE. 485 

Aphasia, too, occasionally accompanies right cortical hemi- 
anopia — /. e., due to a lesion in the left occipital lobe — al- 
though it is not easy to offer a satisfactory explanation of the 
fact. 

But the chief diagnostic symptom is what is known as 
negative vision, ''vision nulle ; " that is to say, the patient, 
though he may be aware of the loss of half of his visual 
field, has no sensation of darkness in it, and is just as un- 
conscious of the defect as a healthy person is of his blind 
spot. 

Cortical hemianopia may be a distant symptom. Gowers 
has observed that, at the onset of many attacks of cerebral 
hemorrhage, hemianopia is present as a distant symptom of 
very fleeting character, so transitory, indeed, that it does not 
complicate attempts at localization ; but I have seen it to last 
as long as three weeks. Except under this condition, distant 
hemianopia seems to be rare, a fact which enhances the local- 
izing value of the symptom. 

Cortical hemianopia may be incomplete, inasmuch as the 
homonymous quadrant only of each field may be wanting. 
The explanation of this has been given, when speaking (p. 
480) of the correlation of the visual cortical centers to parts 
of the retina. 

So much for absolute hemianopia. But the lesion may be 
such as to destroy only the color-sense, without reaching 
those for form and light. Eight cases of hemiachromatopsia 
are on record. 

Again, the form-sense may be lost in the half field along 



be due to pressure. In short, we do not yet know what produces these symptoms 
— they may be caused by inhibition — we only know that they are the result of 
interference with functions of parts of the brain not involved in the lesion, and the 
term "distant symptom" conveys this idea, although perhaps not quite gram- 
matically, without, committing us to any theory. The corresponding German 
term is " Fernwirkung." 



486 DISEASES OF THE EYE. 

with the color-sense, while only the light-sense is retained. 
Furthermore, cases of hemianopia are on record in which, in 
part of the defect, both the color- and form-senses were ab- 
sent, but the light-sense present, while in the remainder of the 
defect all three visual perceptions were lost. 

It is generally held that lesions of the optic radiations 
cause homonymous hemianopia, but it has not yet been proved 
that they are all really visual fibers. Henschen believes that 
only a small portion of them can be regarded as such, while 
Vialet's investigations * seem to show that the visual patch 
includes the whole of the optic radiations. A lesion here 
would be distinguished from one in the cortical center by the 
possibility of hallucinations of vision occurring in the former 
and not in the latter; and further, there would not be ''vision 
nulle " in the hemianopic defects from lesion in the optic 
radiations. Lesions of the posterior third of the posterior 
limb of the internal capsule (Charcot's "sensory cross way ") 
are still believed to cause hemianopia and hemianesthesia of 
the opposite side of the body ; but analysis of clinical cases 
affords no support to this view, for there are no recorded cases 
which furnish any definite evidence in this respect. Yet, ana- 
tomically, fibers have been traced from the occipital cortex 
through the optic radiations and internal capsule to the basal 
ganglia, and from thence into the optic tract. The fibers 
passing through the internal capsule from the external genic- 
ulate body may perhaps be simply reflex fibers. 

The symptoms due to lesion of the primary optic ganglia 
(pulvinar, anterior corpus quadrigeminum, and external gen- 
iculate body) have not been as yet ascertained, the clinical 
evidence being indefinite. In lesions of the pulvinar alone two 
typical symptoms occur, viz. : hemianopia and athetosis, and 
sometimes hemianesthesia may be present. 

* Annates if Oculist., March, 1 894. 



FOCAL BRAIN DISEASE. 487 

Hemianopia from lesions of the optic tract is characterized 
by the absence of such symptoms as mind-blindness, word- 
blindness, etc., which are apt to occur in cortical affections, 
and by the presence, probably, of other symptoms pointing 
to a basal lesion. The defects in the fields may be relative 
(hemiachroniatopsia) or incomplete (only homonymous quad- 
rants being lost). Lesions of the optic tract are, of course, 
apt to implicate the crus cerebri, but do not necessarily do so ; 
and then we would have hemiplegia of the opposite side of 
the body associated with the hemianopia. Symptoms may 
also be caused by implication of cranial nerves, especially of 
those which supply the orbital muscles. 

Atrophy of the optic nerve, and sometimes neuritis, accord- 
ing to the nature of the lesion, are frequently present. 

The characteristic sign which enables us to localize a lesion 
in the optic tract from one elsewhere causing hemianopia, 
is the hemiopic pupil (Wernicke's pupil-symptom). Illumina- 
tion of the amaurotic half of the retina produces a more 
sluggish reaction than when the light is thrown on the sound 
side, or, there may even be no contraction at all ; because the 
lesion is on the distal side of the corpora quadrigemina, and, 
consequently, the impulse cannot reach Meynert's fibers to be 
conducted to the center for the third nerve (see pp. 326 and 
334). It must be stated that some observers deny the occur- 
rence of the hemiopic pupil. But, on the other hand, many 
observers have obtained the symptom. I have myself observed 
it twice. A great obstacle in observing it lies in the difficulty 
of concentrating the light on the blind side of the retina with- 
out allowing it to fall on the good side. It is true that, if the 
pupil-fibers in the optic nerve run as Bechterew thinks they 
do (p. 327), the hemiopic pupil could not occur. If present, 
this is a valuable sign ; but its absence is not decisive, on 
account of the difficulty of obtaining it. 

The forms of diseased process causing a lesion of the optic 



488 DISEASES OF THE EYE. 

tract are : syphilitic gummata and syphilitic meningitis ; new 
growths, including tubercle ; softening and hemorrhage are 
rare. Tumors of the optic thalamus, lenticular nucleus, or 
temporosphenoid lobe may also injure the tract by extension 
or pressure. 

TJie prognosis for recovery of vision in the defective half of 
the fields depends, of course, upon the nature of the lesion ; 
but recovery does not usually take place, especially in the 
most common class of cases ; those, namely, which are due to 
cerebral apoplexy. 

In right homonymous hemianopia, wherever the position 
of the lesion may be, a greater difficulty in reading is ex 
perienced than in left hemianopia. This is partly due to the 
fact that we read from left to rig-ht ; and that, owino- to the 
defect being on the right side, the word immediately following 
that at which the patient is looking cannot be seen at the same 
moment. Knies offers another explanation ; namely, that, 
owing to the right-sided defect, there is loss of the fine 
coordinated movements of the eyes to the right. 

Alexia (a, priv. ; Uhq, speech), or word-blindness, is the 
term given by Kussmaul to an inability to understand written 
or printed characters, although they and other small objects 
can be distinctly seen. Other visual objects are named with 
ease (no visual aphasia). The patient can express his ideas in 
writing, or write from dictation, yet cannot understand what 
he has just written, nor can he copy written or printed words. 
He does understand the meaning of spoken words, and the 
use of all objects around him (no mind-blindness). He can 
generally recognize individual letters with some difficult}'. 
This is " pure word-blindness," or " subcortical alexia." When 
combined with inability to write spontaneously or from dicta- 
tion it is known as *' cortical alexia " (Wernicke). The 
condition has been occasionally complicated with hemianopia. 
In those cases where an autopsy was obtained, the lesion was 



i 



FOCAL BRAIN DISEASE. 489 

found in the left occipital lobe. Word-blindness with agraphia 
or cortical alexia is due, according to Dejerine and Wernicke, 
to a lesion in the center for visual memory for words, which, 
in right-handed people, is the left angular gyrus, and inferior 
parietal lobule. 

Visual aphasia consists in ability to name objects seen, the 
use of which is known. The objects can be named, if the 
patient be alloAved to feel them, even with his eyes closed. A 
few cases of this affection have been recorded, and in all there 
was right homon}'mous hemianopia. Alexia and agraphia 
sometimes coexisted. 

Dyslexia. — This symptom was first described b}' Berlin."^ 
In a wide sense it belongs to the aphasic group. It consists in 
a want of power on the patient's part to read more than a very 
few — four or five — words consecutively, either aloud or to 
himself The difficult}' is not caused b}- dimness of sight, nor 
by pain in the eye or head, but simply by an unconquerable 
feelino; of dislike or diso-ust, due to the mental effort. After a 
few words which can be well understood have been read, the 
book is pushed awa}-, and the head drawn backward and 
turned aside ; and then in a moment or two the patient ma}' 
be tempted to repeat the effort, but with the same result after 
a very few words have been read. The symptom comes on 
suddenl}^, and has been usualh' the first sign of the presence 
of cerebral disease. Although in most of the cases the dys- 
lexia disappeared in the course of a few weeks, either perma- 
nently or to recur later on, yet other symptoms soon followed 
its first onset, such as headache, giddiness, aphasia, hemian- 
opia, paralysis of the tongue, hemianesthesia, hemiplegia, 
twitching of the facial muscles, etc. Seven or eight cases are 
on record, and all have ended fatallv. The lesion was situated. 



^ Archiv f. Psych., Vol. xv, p. 276, and in his monograph, " Eine besondere 
Art der Wortblindheit ■ ■ (Dyslexic), Wiesbaden. 1S87. 
41 



490 , DISEASES OF THE EYE. 

in all but one of those cases where an autopsy was obtained, 
in the neighborhood of Broca's lobe. In one case the left 
hemisphere was normal, while the right hemisphere was ex- 
tensively diseased. 

Amnesic color-blindness is a symptom which is most 
probably due to a lesion in the occipital lobe, interrupting the 
paths between the center for vision and the speech center. It 
has always been accompanied by right homonymous hemian- 
opia. In this condition the patient sees colors and can recog- 
nize them, and he can perform Holmgren's tests, but he is 
unable to name each color. 

Visual hallucinations may occur in cases of homonymous 
hemianopia in the blind side of the field only, being due to 
irritation of the visual-memory center. Homonymous hemi- 
opic hallucinations, persisting for years without hemianopia, 
have also been observed. Visual hallucinations also occur 
very occasionally in connection with glaucoma, and of this I 
have seen an example. Hallucinations differ from illusions in 
that the former are completely subjective, while the latter are 
perverted sensory impressions. 

Mind-blindness, also called optic amnesia, is a symptom 
first observed by Munk * in his experiments upon animals. It 
consists in the loss of power of recognizing objects, while the 
power of seeing them continues. A whip is seen by the ani- 
mal, but inspires no terror ; a tempting morsel is seen, but 
excites no desire. The symptom was caused by destruction 
of a region situated chiefly in the posterior division of the 
second external convolution of the dog's brain. Ferrier f 
seems disinclined to accept Munk's experiments. The symptom, 
however, has also been observed in man. The patient fails to 



*" Zur Physiologic der Grosshirnrinde," Archiv f. Anat. ttnd Physiol. ,\ and 
vi, pp. 162 and 547. 



I Ferrier, " Functions of the Brain," second ed., p. 298. 



DIFFUSE BRAIN DISEASE. 491 

recognize the most familiar objects by sight. In a case of my 
own the patient could not recognize his own wife until she 
spoke. There are two forms of mind-blindness — the cortical 
and the transcortical. In the former the lesion is in the center 
for memory ; and in it the patient has lost the power of visual 
imagination, and cannot describe visual objects from memory. 
In the latter, the connecting path between the center for vision 
and the visual memory center is interrupted, and the patient, 
though he can describe an object from memory, is unable to 
recognize it when looking at it. Hemianopia is present in the 
majority of cases of mind-blindness ; and color-blindness, com- 
plete or hemiopic, is not unusual. The lesion has been found 
in the occipital lobe, sometimes involving the parietal convolu- 
tions. It usually consists in hemorrhage or softening, and the 
symptom is consequently sudden in its onset ; but it also occurs 
from tumors. Exhausting illnesses reducing the mental energy 
may produce a condition of mind-blindness. 

Some authors localize the center for visual memory in the 
angular gyrus, whilst others take for it the whole of the occi- 
pital lobe except the cuneus and its neighborhood. 



Part II. 

OCULAR DISEASES AND SYMPTOMS LIABLE 
TO ACCOMPANY CERTAIN DIFFUSE OR- 
GANIC DISEASES OF THE BRAIN. 

There are organic diseases of the brain which are not focal, 
and which, as they attack extensive regions of the brain sub- 
stance, may be called diffuse. Under the same heading may 
be placed some diseased cerebral states which we cannot doubt 
are organic, although their pathology is as yet unascertained. 
I propose here to describe the points of ophthalmologic in- 
terest which accompany some of these diseases. 



492 DISEASES OF THE EYE. 

Disseminated Sclerosis of the Brain and Spinal Cord. — 
Central color scotoma is the most usual defect of sight in this 
disease, and in a few cases absolute central scotoma is present. 
Irregular defects in the periphery of the fields, sometimes only 
for color, or regular concentric contraction may be found. 
These defects may be in one or in both eyes ; they most com- 
monly come on very rapidly, and they may get better, or, 
after a time, get quite well. Even complete blindness, lasting 
as long as several months, may occur ; but permanent com- 
plete blindness is rare. The ophthalmoscopic appearances do 
not always coincide with the state of the vision ; for with 
marked defect of sight the fundus oculi may be normal, or 
the vision may be normal, while the optic papilla looks dis- 
eased, or both sight and ophthalmoscopic appearances may be 
abnormal. The most common ophthalmoscopic change is a 
not very intense atrophic appearance of the whole surface of 
the papilla, or its temporal third alone may be affected in this 
way. But in these latter cases, where the temporal third alone 
shows atrophy, a central scotoma is not necessarily present, 
nor are the papillomacular fasciculi in the nerve diseased. In 
a very few cases optic neuritis is present. The ophthalmoscopic 
changes may be in both eyes or in only one. Hemianopia has 
not been noted, and therefore the defects of vision are evi- 
.dently always due to disease in the optic nerve, and not in the 
chiasma or tract. Uhthoff has shown that in disseminated 
sclerosis there may be disease in the trunk of the optic nerve, 
without any abnormal ophthalmoscopic appearances, or defect 
of sight. Sometimes defects of vision and ophthalmoscopic 
changes precede all other symptoms by long periods, or they 
appear in the very early stages of the disease ; but more com- 
monly they do not come on until other symptoms have been 
present for some time. 

Isolated paralyses of orbital muscles, nuclear paralysis, and 
nystagmus are derangements of the oculomotor apparatus, 



DIFFUSE BRAIN DISEASE. 493 

which are hable to be present in disseminated sclerosis. 
Marked exterior ophthalmoplegia is rare, but the paralyses of 
nuclear origin, of which there can be no doubt, are loss of 
conjugate motion to one or other side, and defective power of 
convergence. Nystagmus is present in about 50 per cent, of 
the cases, and is either of the ordinary kind or consists merely 
in nystagmic twitchings, more particularly at the extreme 
lateral positions of the eyeballs. Very slight twitchings in 
these extreme positions are of no import, as they occur even 
in the healthy state. As true nystagmus is an uncommon 
symptom in other diseases of the general nervous system, it is 
of value in this diagnosis. Nystagmic twitchings, while they 
do occur in other general nervous diseases, are more common 
in disseminated sclerosis than in other of these diseases. 

Disseminated sclerosis in its early stages is apt to be mis- 
taken for hysteria, owing to the presence of such symptoms 
as transitory loss of power in limbs, aphonia, convulsive 
seizures, hysteric manner, and so on, and here the eye- 
symptoms may come to our aid. In hysteria the ophthal- 
moscopic appearances are normal ; the fields of vision, if 
deranged, are contracted, central scotoma being rare, and 
when the fields are contracted the color boundaries often do 
not recede in their regular order — the field for red, for ex- 
ample, may be wider than that for the other colors. In 
hysteria, again, it may be found impossible to examine the 
color fields at all, colors being named dark or black ; and, 
finally, oculomotor disturbances rarely occur. 

Diffuse Sclerosis of the Brain. — In some rare cases of 
this disease headache, vomiting, and double optic neuritis may 
lead to the diagnosis of cerebral tumor, an error in diagnosis 
which, with our present knowledge, it is impossible to avoid, 
unless there be also focal symptoms that would point with 
certainty to a tumor. The mistake will not often occur, as the 
cases here indicated are exceedino-ly rare. 



494 



DISEASES OF THE EYE. 



General Paralysis of the Insane. — Derangements of the 
intrinsic muscles of the eyeball, orbital paralyses, atrophy of 
the optic disc, and mind-blindness are the eye-symptoms which 
may be found in this disease, 

TJlc Piipil^ etc. — The pupils are usually contracted in the 
early stages, and dilated at later periods. An early symptom 
is slight inequality in the pupils, with somewhat sluggish re- 
action of the wider one, and, also at an early period, there is 
apt to be loss of the pupil-reflex to sensory stimuli. Later on 
the larger pupil does not react to light at all, while its fellow 
does so normally, and sight is good. The so-called paradoxic 
pupil-symptom is an early augury of coming paralysis, and 
consists in this, that when a strong beam of light is thrown 
into the eye with the focal illumination, the pupil at first con- 
tracts fairly well, then dilates slightly, contracts again, and after 
a few such oscillations finally dilates widely, although the 
strong light still shines into the eye. The Argyll Robertson 
pupil is only found in some cases, and then usually in the late 
stages, but it does occasionally present itself in the initial 
stages. Sometimes the pupil is irregular in shape. 

Paralyses of Orbital Muscles. — These are of rarer occurrence 
than paralysis of the pupil ; but the third and sixth nerves are 
occasionally paralyzed even in the early stages, and in these 
stages, too, ptosis, and transient nystagmus and twitchings of 
the eyelids may be seen. 

Optic Atrophy. — This is rare in general paralysis, and is then 
seen for the most part in the late stages. But it has some- 
times come on in a very early period, and has even preceded 
every other symptom by several years. 

Mind-blindness occurs in cases of general paralysis, usually 
in the advanced stages. 

Meningitis. — Inflammation of the cerebral meninges, of 
whatever form, and whether at the base or on the convexity of 
the brain, is liable to be accompanied by optic neuritis. When 



DIP^FUSE BRAIN DISEASE. 495 

the meningitis is at the base, ocular paralyses, pain, or anesthesia 
of regions supplied by the fifth nerve, and defects in the fields 
of vision from pressure on the optic tracts or commissure may 
be found. 

Acute Tubercular Me/iingitis. — In a small percentage of the 
cases of this form of meningitis miliary tubercles in the choroid 
are present. Optic neuritis is more common than in any other 
form of meningitis, as are also orbital paralyses, in consequence 
of its tendency to attack the base of the brain. 

Cerebrospinal Meningitis. — Eye-symptoms are often present, 
both in the epidemic and sporadic forms of this disease. 
Swelling of the eyelids, conjunctivitis, and photophobia are 
frequent even in the early stages. The pupils may be un- 
equal, contracted, or dilated. There may be ulceration of the 
cornea, parenchymatous keratitis, or deep purulent infiltrations. 
Retinitis and plastic iridochoroiditis, followed by retinal de- 
tachment, may be found, or there may be purulent irido- 
choroiditis, with purulent infiltration of the vitreous humor, 
going on to panophthalmitis. If the fundus can be examined 
optic neuritis or neuroretinitis will often be seen, or thrombosis 
of the central vein, with retinal hemorrhages. Each epidemic 
of cerebrospinal meningitis is apt to be associated with some 
one of these conditions as its special type of eye-affection. 
The eye-affections in cerebrospinal meningitis then are very 
grave ; but some of the cases of iridochoroiditis do recover, 
with retention of good sight. 

Traumatic Meningitis. — Falls and blows on the head 
which do not fracture the skull are held by many to be capable 
of causing meningitis, and that, occasionally, the inflammatory 
process, reaching the optic nerve, creeps down it to the optic 
papilla, where it may be diagnosed with the ophthalmoscope. 

Hydrocephalus. — Well marked papillitis or neuritic atrophy 
is sometimes found in congenital hydrocephalus, or in the 
hydrocephalus which makes its appearance in infancy, and 



496 DISEASES OF THE EYE. 

would probably be more common but for the compensation 
for the increased intracranial pressure which distention of 
the sutures and fontanels must provide. In the acquired 
hydrocephalus of later life, optic neuritis passing over the 
optic atrophy is the rule, and such cases may closely simulate 
an intracranial tumor in all their other symptoms as well. 
Bitemporal hemianopia is apt to be present, owing to pressure 
on the optic commissure by the distended floor of the third 
ventricle. 

Infantile Paralysis. — Hemianopia has been noted in a 
very few cases of this affection ; and papillitis, with some orbital 
paralysis has also been seen, but usually there are no eye- 
symptoms. 

Paralysis Agitans, or Parkinson's Disease. — In some 
cases a fine vibratory tremor may be noticed along the margin 
of the upper lid, especially when the eyes are closed, and the 
lids will be found to be unusually rigid on an attempt being 
made at passive opening of them. The slowness of muscular 
action in other parts does not affect the motions of the eye- 
balls. If a patient be directed to look in any direction, the 
eyes are instantl}' turned, while the head slowly follows them. 

Encephalopathia Saturnina. — Even in the milder cases, 
transient hemianopia or amaurosis, which may last for several 
hours, is sometimes met with. There need be no renal disease, 
and the visual defect must be taken as the result of the lead- 
poisoning on the brain. In those cases in which acute cerebral 
disturbance sets in (convulsions, delirium, coma) it is often 
attended by optic neuritis, with considerable swelling of the 
disc, and retinal hemorrhages. 

Sometimes the fields are contracted without ophthalmo- 
scopic appearances, as in hysteria. The pupils may be un- 
equal. As headache, vomiting, and convulsions are symptoms 
of bad ca.ses of lead-poisoning, it is evident that when intense 
optic neuritis is added, the diagnosis between this disease and 



DIFFUSE BRAIN DISEASE. 497 

cerebral tumor has to be considered. The characteristic blue 
line on the gums, anemia, colic, constipation, dropped wrist, and 
lead in the urine are the aids to the diagnosis, along with the 
previous history and the patient's occupation. 

Epilepsy. — A visual aura is more common than any other 
special sense aura in idiopathic epilepsy. It may take the 
form of subjective sensations of lights, color, flames, megalopsia 
or micropsia, etc. ; or visual hallucinations may occur ; or there 
may be simple homonymous hemianopia. Where epilepsy is 
due to organic brain disease, a visula aura, occurring always 
in homonymous sides of the fields, is important as indicating 
the occipital lobe as the region of the brain in which the dis- 
charge originates. At the onset of an epileptic fit there is 
often conjugate lateral deviation of the eyes to the opposite 
side of the body from that on which the convulsions commence, 
with rotation of the head in the same direction, while sub- 
sequently the eyes may suddenly be turned in the opposite 
direction. The condition of the pupils vary, often even in 
one and the same fit. At the onset they are usually normal 
or contracted ; but during the tonic spasm they become 
dilated, and remain so until consciousness returns. The 
pupillary light-reflex is lost — a point of importance in the 
diagnosis of a true epileptic fit from an hysteric attack, in 
which latter it is retained. After a fit rapid changes in the 
size of the pupil may sometimes be seen, and these are 
valuable as evidence of the fit having been a genuine one. 
The ophthalmoscopic appearances during a fit vary in different 
cases. In some they are normal, in others there is marked 
pallor of the disc and contraction of the blood-vessels, and, 
again, in others the papilla is hyperemic and the retinal veins 
enlarged. Optic neuritis and optic atrophy do not belong to 
epilepsy ; and if found they can be regarded only as com- 
plications. Between attacks the fundus may be normal ; but 
it is not unusual to find a high degree of hyperemia of the 
42 



498 DISEASES OF THE EYE. 

retina and papilla, which may continue for some days or hours, 
or may even become chronic. The fields of vision after a fit, 
and sometimes as a permanent state, are concentrically con- 
tracted ; or there may be color-blindness, and the central 
acuteness of vision may be reduced. The state of the fields 
is a valuable aid in the detection of stimulation. Transitory 
amblyopia (migraine, scotoma, etc.) is more frequent in con- 
nection with epilepsy than under any other condition. It may 
precede the true attack by years, or it may occur with, or for 
an hour or so before, the fits, or it may be substituted for them. 
Inasmuch as this transitory amblyopia is often attended by 
disturbances in speech, in the intelligence, or by passing 
paralysis, and as both eyes are usually attacked by it, fre- 
quently in the form of homonymous hemianopia, it is obvious 
that its cause resides in the visual cortex. Occasionally the 
blindness is monocular, and must then be referred to dis- 
turbance in the circulation of the retina or optic nerve. It" 
is held by some authorities that, given a predisposition to 
epilepsy, irregularities in refraction may at times prove the 
exciting cause of the disease, and that cases of epilepsy occur 
in which the attack is induced by the undue strain put upon 
the muscular apparatus of the eye by reason of an abnor- 
mality of refraction. They also hold that, if correcting 
glasses be worn by these patients at a sufficiently early period, 
the fits will cease, or at least in a considerable proportion of 
the cases. Further investigations on this subject are required, 
especially as concerns the permanence of cures. 

Chorea. — It is probable, I think, that in some cases at 
least of this affection cerebral embolism may be taken as the 
cause. Several instances of embolism of retinal vessels have 
been seen in immediate connection with the onset of chorea. 
In chorea the eyes participate in the irregular jerky motions, 
and the spasm may be so unequal in the two eyes as to cause 
brief diplopia, although, not being constant, it is little heeded 
by the patients, and is rarely mentioned by them. 



SPINAL DISEASE. 499 



Part III. 



OCULAR DISEASES AND SYMPTOMS LIABLE 

TO ACCOMPANY CERTAIN DISEASES AND 

INJURIES OF THE SPINAL CORD. 

Tabes Dorsalis. — Amongst the ocular complications to 
be found in this disease, atrophy of the optic nerve is the most 
serious. It occurs in about 20 per cent, of the cases, and 
commences more frequently in the preataxic period than 
subsequently. Rarely it is the first symptom, preceding all 
spinal symptoms by from two to twenty years, and it does 
sometimes commence in the later stages of locomotor ataxia. 
Coming on in the preataxic stage, optic atrophy seems very 
often to have, as Benedikt first pointed out, a favorable influ- 
ence on the spinal disease, the spinal symptoms already ex- 
isting becoming ameliorated or disappearing, while the further 
progress of the disease is retarded or averted. It is, indeed, 
rare for tabetic patients who go blind at an early stage of the 
disease to become ataxic later ; but if the ataxia has become 
well marked, it does not improve with a subsequent develop- 
ment of optic atrophy. It sometimes occurs that the onset of 
optic atrophy in one eye precedes that in the other by a long 
interval, even by many years ; but usually the eyes are affected 
simultaneously, or with a very short interval. The relation 
between the optic atrophy and the spinal disease is not as yet 
well understood. The atrophy is probably merely a manifes- 
tation of a diseased process in the optic nerve, similar to that 
which attacks the posterior columns of the cord. 

Paralysis and Ataxia of the Orbital Muscles. — Paralyses of 
orbital muscles in locomotor ataxia occur in about 30 per cent, 
of the cases. They usually appear in the preataxic stage, and 
even as an initial symptom, and are of two kinds — namely, 
the transient paralysis, which lasts a few days or weeks, and 



500 DISEASES OF THE EYE. 

may recur, and the permanent paralysis of one or two muscles. 
Diplopia is produced by these paralyses, and is often the symp- 
tom which first induces the patient to see his doctor. The 
sixth nerve is the one most commonly paralyzed ; but the 
third nerve is also often paralyzed, including the branch to 
the levator palpebrse, with resulting ptosis. Loss of power 
of convergence is often present in commencing tabes, and 
double exterior ophthalmoplegia, as well as double sixth- 
nerve paralysis, is sometimes seen ; and there can be no doubt 
but that all tliese three conditions, and probably also some of 
the other oculomotor disturbances in tabes, are of nuclear 
origin. But the orbital nerves may, it is found, undergo 
atrophy without their nuclei being altered, and probably, 
therefore, some of the ocular paralyses here are due to per- 
ipheral neuritis. 

Ocular ataxia is another not infrequent symptom in tabes. 
It is sometimes erroneously called nystagmus ; but nys- 
tagmus is a constant oscillatory motion of the eyeballs, both 
while the eyes are at rest, and when they are looking at an 
object, and is extremely rare in tabes. In ocular ataxia, so 
long as the eyes are at rest, there is no oscillation or twitch- 
ing ; but as soon as an object is carefully looked at, and espe- 
cially if followed when in motion, and more particularly at 
the end of the latter, a slight twitching of the eyeballs is seen. 
It may be found in any stage of tabes. 

Pupillary Alterations. — Miosis is the usual state of the 
pupil in tabes, and is held to be due to paralysis of the pupil- 
dilating fibers from disease in the front part of the aqueduct 
of Sylvius. The miosis is often extreme, or " pin-hole," as 
it is then termed ; yet the pupil may react to light and on 
convergence. The pupil may be of normal size in tabes ; but 
mydriasis, except as part of a third-nerve paralysis, is rare. 
Again, both in the early and later stages the pupils may be of 
different sizes. The Argyll Robertson pupil is an important 



SPINAL DISEASE. 501 

symptom of tabes. It consists in this : that the pupil, although 
as a rule contracted, does not respond to the stimulus of light 
by further contraction, or, if so, but slightly ; yet does become 
more contracted on convergence of the visual axes, or on ac- 
commodation. ^Miosis need not necessarih' be present with 
the Argyll Robertson pupil ; the pupil may be of normal size 
or dilated. The symptom is one of those most regularh- 
found in tabes. It is often an earh' or initial s}-mptom, and it 
continues through all the stages of the disease. It is occa- 
sionally present in one eye only, and is sometimes quite want- 
ing. Neither the Argyll Robertson pupil nor primary optic 
atroph}- occurs in peripheral neuritis, a disease which is liable 
to be sometimes mistaken for tabes. 

Paralysis of accomniodation without paral}'sis of the sphincter 
iridis is a rare symptom in tabes. It is more common in the 
late than in the early stages. 

Narroiving of tJie palpebral fissjirc, due to a slight drooping 
of the e}'elids, hardly to be called ptosis, sometimes occurs in 
tabes along with the miosis. It is held to be due to paralysis 
of the sympathetic (sympathetic ptosis), is usually binocular, 
and the frequenc\- of its occurrence increases as the disease 
advances. 

Twiichings in the 07'bicula7ns nniscle for some viouients after 
closure of the eyelids may sometimes be obser\-ed in tabes. 
Similar twitchings may occasionally be seen in some other 
nervous diseases, and even in health, but less well marked. 
Probably their marked character in tabes is due to very slight 
facial paralysis, and the consequent imperfect power of closing 
the eyelids. 

Epiphora is stated by some authors to be not rare in tabes ; 
but others deny this, and I have not myself observed it to be 
so. 

Reduction of intraocular tension is a s\-mptom in tabes to 



502 DISEASES OF THE EYE. 

which as yet Berger alone has drawn attention. He found it 
present in 35 out of 109 cases examined. 

Hereditary ataxia (Friedreich's disease) has few eye- 
symptoms, a fact of some diagnostic importance. Ataxic 
nystagmus is the only one which occurs with any constancy, 
as Friedreich pointed out. Optic atrophy is of such rare 
occurrence in the disease that it can hardly be reckoned as one 
of its symptoms. Paralyses of orbital muscles do not occur, 
nor does any pupil-symptom. 

Myelitis, — Apart from the inflammation of its meninges 
(cerebrospinal meningitis), of which I have already spoken, 
acute inflammation of the cord may be associated with optic 
neuritis. The optic nerve seems usually to become inflamed 
before the spinal cord, but the myelitis may precede the optic 
neuritis, or optic nerve and spinal cord may be simultaneously 
attacked. The relation of the optic neuritis and myelitis to 
each other is, doubtless, nothing more than that each is a 
manifestation of the presence in the system of one and the 
same toxic influence, whatever it may be. Rheumatism, epi- 
demic influenza, and syphilis are amongst the causes assigned 
in some cases, while in others no cause could be assigned. 
If the cervical portion of the cord is inflamed, pupillary symp- 
toms (irritation mydriasis or paralytic miosis) are apt to be 
present. 

Syringomyelia and Morvan's Disease. — One eye-symp- 
tom is common to both of these diseases, which are, indeed, 
held by many to be one and the same disease — namely, a 
concentric contraction of the field of vision without ophthalmo- 
scopic changes. It is not quite certain whether this abnor- 
mality of the field is due, at least sometimes, to attendant 
hysteria, or is always a symptom of the organic disease as 
such. Inequality of the pupils has sometimes been noted. 

Myotonia Congenita (Thomsen's Disease). — In some 



SPINAL DISEASE. 503 

cases of this rare disease the external musculature of the eyes 
affords symptoms, although the intrinsic muscles are never 
disordered. The opening and closing of the eyelids may be 
difficult — they cannot be closed or opened at one stroke, suc- 
cessive jerky motions being required to effect closure or 
opening. As in Graves' disease, when the eyes are open the 
upper lid is apt to be retracted, and the upper lid does not 
readily follow the downward motions of the eyeball. Transi- 
tory amblyopia, or even amaurosis, has been noted in some 
cases. 

Acute Ascending Paralysis (Landry's Disease). — 
Eye-symptoms are rare in this disease, but there may be 
paralysis of some of the orbital muscles, paralysis of accom- 
modation, mydriasis, or loss of the light-reflex. 

Injuries of the Spinal Cord. — The condition which used 
to be known as railway spine, but \\'hich is now better styled 
traumatic neurosis, and is due to mental shock rather than 
to organic lesions of the brain and spinal cord, is accompanied 
frequently by certain functional eye-symptoms, of which the 
chief one is a contraction of the field of vision similar to 
that found in some cases of hysteria. In those much rarer 
cases of organic injury to the cord, or of myelitis, or of 
hemorrhage in or inflammation of its membranes, following 
on railway and other accidents, organic eye-disease seldom 
results, although optic neuritis and optic atrophy used to be 
held to be frequent consequences of these injuries. If the 
lesion be in the lower cervical region of the cord, the pupils 
are apt to be contracted from sympathetic paralysis. 



504 DISEASES OF THE EYE. 



Part IV. 

NERVOUS AMBLYOPIA, OR NERVOUS 
ASTHENOPIA. 

We find nervous amblyopia, or nervous asthenopia, for the 
most part in connection with three functional disorders of the 
nervous system — namely, neurasthenia, hysteria, and traumatic 
neurosis. Many observers, it is true, hold that these three 
conditions ought to be regarded and treated of as hysteria, 
that the term neurasthenia is quite superfluous, while trau- 
matic neurosis is merely hysteria caused by shock. This is 
not the place to enter into a discussion on this question ; and 
it is only necessary to say, that while these various states of 
the nervous system are admitted on all hands to have much 
in common, and also to merge insensibly into each other, yet 
typical cases of each are sufficiently differentiated to make it 
justifiable and convenient for the present to retain all three in 
our minds as separate clinical entities. 

The defects of vision which accompany these disorders are, 
like all their other symptoms, purely functional — /. ^. , they do 
not depend on any organic disease- in the retina or other 
portions of the visual apparatus, but merely upon derange- 
ment of the functions of these parts. Consequently, there 
are no ophthalmoscopic changes in the fundus oculi. 

In the following the derangements of vision most liable to 
be found in each condition will be pointed out, but here it is 
desirable in the first instance to state them in a general way. 
Complete blindness of one or both eyes may be found, but 
is rare ; a diminished, but fluctuating, acuteness of vision is 
more common, the effort or desire to see well being often the 
signal for the acuteness of vision to fall, or objects disappear 
from sight if looked at long. Attacks of defective sight, too, 
may come on suddenly without any provocation, accompanied 



liiL 



NERVOUS AMBLYOPIA. 505 

by positive scotomata, and may last for some minutes. But 
the most remarkable, important, and characteristic symptom 
is concentric contraction of the fields of vision. It is almost 
ahvays necessary, in order to ascertain the presence of this 
symptom, to examine the fields with the perimeter — no 
rougher method will answer — and it is most important to use 
a test object of not more than five mm. square. Concentric 
contraction of the fields is, we know, a symptom in optic 
atrophy and in glaucoma ; but, while in those diseases the 
contraction usually advances with more or less deep reentering 
angles directed toward the fixation-point, in nervous amblyopia 
the contraction is about equal in degree in each meridian, and 
hence the seeing portion of the field which is left presents a 
somewhat circular shape. This shape of the field, with normal 
ophthalmoscopic appearances, is pathognomonic of the condi- 
tion. The contraction may be but slight, or it may approach 
to within ten degrees or five degrees of the fixation-point. 
It is almost invariably present in both eyes, but it is often 
much more marked in one eye than in the other. 

Associated sometimes Avith this concentric contraction, and 
sometimes without it, is a phenomenon known as the fatigue 
field. It consists in this, that if the test-object be brought 
from the periphery toward the fixation-point in each meridian 
successively, it will be found that the outside limit of the field 
is nearer the fixation-point on each successive meridian exam- 
ined, without regard to the part of the field in which the ex- 
amination is commenced ; or, if the test-object be brought in 
the horizontal meridian from the periphery on, say, the temporal 
side across the field until it disappears on the nasal side, and 
the points of entrance and of exit noted, and the object be 
immediately carried back on the same meridian until it disap- 
pears on the nasal side, and the entrance and exit again noted, 
and this manoeuver repeated five or six times, should fatigue 
be present, it will be shown by the points of entrance and exit 



5o6 DISEASES OF THE EYE. 

coming nearer and nearer to the fixation-point on each journey 
— in short, the field is becoming more and more contracted. 
This method of taking the field in these cases has been pro- 
posed by Wilbrand,* and is useful, too, as showing whether at 
the beginning there is any concentric contraction of the field. 

These two modes of examination are practically the same ; 
and the reason for the form of fields they are intended to bring- 
out is, that the longer in each case the examination is con- 
tinued, the more fatigued does the nervous visual apparatus (be 
it cerebral center, or retina, or both) become, and this exhaus- 
tion is most marked in the periphery of the field. In the 
normal state the boundary of the field is not much affected 
by the length of the examination. Ring-form and island-like 
defects in various parts of the field, and which come and go, 
are recognized as functional defects, and cannot be confused 
with the continuing central scotoma of toxic amblyopia due to 
disease in the papillomacular fibers. In addition to the de- 
fective sight, or contraction of the fields, or fleeting scotomata, 
there are often other eye-symptoms present, such as weakness 
of accommodation, or of the internal recti, or some derange- 
ment of the fifth or facial nerves. 

While functional derangements of vision, as distinguished 
from those due to organic disease, are what are here under 
consideration, yet it is very necessary to mention that visual 
defects due to organic disease may sometimes be aggravated 
by functional blindness. In tabes, with optic atrophy, for 
instance, the contraction of the field may become suddenly 
increased with the occurrence of some mental worry or inter- 
current general illness, and become restored again to its former 
dimensions with the return to a calmer state of mind or to 
improved health. In homonymous hemianopia there is often 



■'^Wilbrand and Sanger, " Ueber Sehstorungen bei functionellen Nerven- 
leiden." 



NERVOUS AMBLYOPIA. 507 

a peripheral contraction in the seeing side of the field, which 
can only be due to diminished functional activity in the oppo- 
site side of the brain from that in which the disease is situated. 

In the three disorders of the nervous system mentioned, 
the symptoms may, in a given case, remain confined to the 
nerves which are associated with the various functions of the 
eye ; but this is rare. It is more common to find also symp- 
toms provided by the derangement of functions in other parts 
of the nervous system. 

Nervous Amblyopia in Neurasthenia. — School-children, 
and those of that age, are very liable to become neurasthenic. 
They are brought to the physician with the complaints that 
the sight is confused, that print disappears as they look at it, 
that reading causes the eyes to smart and run over water, and 
that it brings on headache. If the patient be required to read 
aloud he soon stops, complaining that the words are running 
into each other, and the book is then brought closer to the 
eyes ; then a few more w^ords are read, and the book is brought 
still closer, until, finally, it is nearly in contact with the nose ; 
and then further attempts are made to see by twisting the head 
about and turning the book toward the light, frowning, and so 
on. Obviously, what causes this difficulty in reading is a rapid 
exhaustion of the accommodation. Insufficiency of the in- 
ternal recti is also often present, and would contribute to the 
difficulty of use for near work. The eyes are often emme- 
tropic, and the amplitude of accommodation is normal. Ex- 
amination of the fields will often discover them to be concen- 
trically contracted, and the fatigue field, too, is frequently 
present. With these asthenic symptoms there are often 
symptoms of exalted sensibility of the visual apparatus, such 
as photopsia (bright spots, colored balls, glittering surfaces, 
etc., before the eyes), a prolonged continuance of the after- 
images of objects, increased sensitiveness to daylight, and still 
more so to artificial light and visual hallucinations (heads, 



5o8 DISEASES OF THE EYE. 

animals, passing shadows, etc.). In the neurasthenia of school- 
children eye-symptoms often predominate, but other nervous 
symptoms are nearly always present, such as hallucinations of 
hearing, states of uncalled-for joyous excitement, or of mental 
depression, or of irritability of temper. Vertigo, a tendency 
to weep, some loss of memory, and insomnia, may all, or any 
of them be present. The patellar reflex is usually increased. 
Patches of diminished sensation may be found here and there 
over the surface of the body, although completely anesthetic 
patches or hemianesthesia are rare. 

In school-children complaints of difficulty in reading suggest 
malingering in many instances, and it is not wise to adopt this 
view without good grounds for it. An examination of the 
fields may set the question at rest, for neither the concentric- 
ally contracted field, nor the fatigue field can be malingered. 

The neurasthenia of adults manifests itself, so far as eye- 
symptoms are concerned, less in the use for near work than is 
the case with school-children. In them, moreover, the con- 
traction of the fields is usually slight, while the fatigue field is 
well-marked. These patients come complaining of unpleasant 
and painful sensations in and around the eye, such as creeping 
sensations and boring pains in the orbit, stabbings in the eye- 
ball, a sensation as if the eye were turned round in the head, 
uneasy feelings attending the motions of the globe. The eye 
may be very painful on pressure at some one .spot without 
apparent cause ; and there are often uncomfortable sensations 
of cold, burning, or dryness under the lids. If there be an 
error of refraction it is difficult to find glasses with which the 
patient will be content, the bridge and wings of the frames 
annoying them with their slight pressure, while the reflection 
of light from the margins of the eye-pieces causes dazzling. 
The patients are very sensitive to any bright light. The cen- 
tral acuteness of vision is usually normal, but use of the eyes 
for near work causes headache, often in the form of a ham- 



NERVOUS AMBLYOPIA. 509 

mering in the temples, or a sensation of pressure on the 
vertex. 

Treatment. — Tinted protection-spectacles. Abstinence from 
use of the eyes for near work. A general tonic treatment, 
including cold sponge baths when they can be borne, bracing 
air, plenty of exercise in the open air short of fatigue, early 
hours, and easily digested diet. As regards drugs, strychnin 
and iron are those from which most can be expected. 

Nervous Amblyopia in Hysteria. — Nervous amblyopia, 
or nervous asthenopia, in hysteria is often ver}'^ similar to that 
in the neurasthenia of school-children, except that the diffi- 
culty for near work is even greater. Tonic blepharospasm 
and partial paralysis of orbital muscles may accompany it. 
The field of vision is commonly more contracted in one eye 
than in the other, or the contraction may be very marked in 
one field, while the other field is normal or nearly so. In 
neurasthenia the contraction is usually about equal in each 
eye. Orientation is rendered more difficult by the hysteric 
than by the neurasthenic field. A high degree of blindness, 
or even complete amaurosis, may attack a neurasthenic school- 
child for a few minutes. In hysteria such attacks, which may 
occur in both eyes, but are usually confined to one eye, are 
likely to last for weeks or months, or longer. In the amblyopia 
of hysteria we may find that an eye which cannot see moder- 
ately-sized type is enabled to do so by placing any plane glass 
in the form of spectacles before the eye. Such an occurrence 
by no means proves that the patient is malingering ; it shows, 
rather, that the psychic inhibition to the function of sight in 
the eye has been withdrawn by the suggestion provided by the 
spectacles. 

With monocular amblyopia or amaurosis there is usually 
hemianesthesia of the same side of the body as the blind eye ; 
or, if there be merely contraction of the fields, there is often 
hemianesthesia of the side of the most contracted field. 



5IO DISEASES OF THE EYE. 

The pupils vary much in these cases, and even in one and 
the same case from time to time. They may be normal, or 
wide and immovable, contracted, or of different size in each eye. 

Nervous Amblyopia in Traumatic Neurosis. — In trau- 
matic neurosis one of the most important and most constant 
of the symptoms is concentric contraction of the field of vision. 
Yet it is often absent, and when present is not always suffi- 
ciently typical in form to enable it to be utilized in the diagno- 
sis. It is not often so pronounced as to interfere w^th orien- 
tation, and must be sought for with the perimeter to determine 
its presence. The boundaries for the color-fields are affected 
even more than that for white, and consequently the tests for 
these boundaries may discover the contraction more readily 
than examination of the boundary for white. The relative 
position of the color boundaries is seldom altered, and color- 
bhndness is seldom present. The defect in the field is usually to 
be found in both eyes, and if there be hemianesthesia it is on 
the side of the most contracted field. It is an important fact 
that the contraction of the field may be the only derangement 
of sensation, either special or general. The contraction is 
liable to continue for months or years, and to become more 
marked for a time, as the result of any passing mental dis- 
turbance. The fatigue field, too, is present in some cases of 
traumatic neurosis. 

As regards other ocular symptoms in traumatic neurosis : 
the pupil-reflex is usually normal, but is occasionally wanting, 
and a difference in size of the pupils may sometimes be noted ; 
paralyses of orbital muscles are rare, but insufficiency of the 
internal recti is not uncommon ; sensations of sparks, colors, 
and waviness before the eyes are sometimes complained of ; 
photophobia, and sensations of dazzling, with their resulting 
blepharospasm, may be present. 

It is not desirable to rest content with one examination of 
the field of vision, which may prove negative in its result, for 



VARIOUS FORMS OF AMBLYOPIA. 511 

it is only shown thereby that on that occasion the field was 
normal. At a later period a defect may be found. 



Part V. 

VARIOUS FORMS OF AMBLYOPIA. 

Transitory Hemianopia, or Scintillating Scotoma. — 

This affection is characterized by (i) symmetric defects in 
the fields of vision, usually of the hemianopic type, and (2) 
vibrating or scintillating luminous sensations, which after a 
short time disappear, and are followed b}' an attack of (3) mi- 
graine. In fact, the visual troubles belong to the symptoms 
of this latter affection. 

The scintillations and defects in the fields, either of which 
may occur first, commence over a small area, general]}' near 
the macula lutea, and gradually widen out; the flashing in- 
creases in intensity, and often assumes a zigzag shape, like 
fortifications, at the periphery of the defect in the field. And 
this defect may exist as symmetric scotomata, complete or 
partial homonymous hemianopia, or even altitudinal hemi- 
anopia. In some cases the scintillation may be absent, while 
in others the attack of migraine does not follow. The ocular 
symptoms, which last from a period varying from a few 
minutes to half an hour, are not accompanied by any changes 
in the fundus oculi, and always end in complete recovery. 
Vertigo, nausea, or sickness, and even slight aphasia sometimes 
accompany the headache. 

This affection occurs most frequently in intellectually active 
individuals ; fatigue, long reading, and hunger have been 
known to bring on attacks. The symptoms are most probably 
due to disturbances in the cerebral circulation. 

Treatment should be directed to the cause of the migraine. 



512 DISEASES OF THE EYE. 

Lying with the head low, stimulation of the circulation by 
wine or nitroglycerin sometimes cuts short an attack. 

Congenital Amblyopia. — This condition is not very un- 
common. Ophthalmologists, in the course of their practice, 
come across people in whom the vision of both eyes is below 
the normal standard, even with perfect correction of any error 
in refraction, and who declare that they have never seen better, 
and that their sight is not getting worse. Still more common 
is congenital amblyopia in one eye. As a rule, the field of 
vision and the color-vision are normal, but cases are seen in 
which there is contraction of the field, with defective color- 
sight. 

The opJitJialmoscopic appearances are normal. 

Reflex amblyopia is said to have been observed, and 
chiefly in connection with irritation of the fifth pair, especially 
its dental branches ; but I have not seen these cases, and I 
am rather skeptical as to their occurrence. Carious molar 
teeth are reputed to be its frequent cause, usually with severe 
toothache, but sometimes without it. The defect of vision 
may be confined to the side of the carious tooth, and is nearly 
always most marked on that side. It is said that it may be of 
extreme degree, vision being reduced even to the merest per- 
ception of light. 

More generally recognized than amblyopia, as the result of 
toothache, are hyperesthesia of the retina, photophobia, sub- 
jective sensations of light, and diminution in the amplitude of 
accommodation. 

All these symptoms, even amblyopia of the severest type, 
disappear when the dental affection is relieved. 

Many cases are on record in which wounds of the supra- 
orbital nerve were looked on as the cause of amblyopia or of 
amaurosis ; but it is by no means certain that an ophthalmo- 
scopic examination would not have afforded another explana- 
don in many of these cases, Yet even nowadays many hold 



VARIOUS FORMS OF AMBLYOPIA. 513 

that wounds of the supraorbital region can produce amblyopia, 
as cases are said to have been cured by division of the nerve 
involved in a cicatrix that was tender on pressure. 

Sympathetic irritation (p. 315) is to be included under this 
heading. It is seen in the sound eye in some cases of cyclitis, 
and must not be confounded with sympathetic ophthalmitis, 
which comes about in quite a different way. Its symptoms 
are : diminution of the amplitude of accommodation, asthen- 
opia, hyperesthesia of the retina, lacrlmation, and subjective 
appearances of light. 

Removal of the exciting eye, if otherwise indicated, always 
relieves sympathetic irritation ; but where this is not admis- 
sible, the dark room, atropin, dry cupping at the temple, with 
bromid of potassium internally, may be employed. 

The opJitJiahnoscopic appearances in reflex amblyopia are 
normal. 

Nyctalopia (Night-blindness). — This is a well-recognized 
symptom of the disease known as retinitis pigmentosa (p. 
435). I have seen an instance of congenital night-blindness 
in five members of a family of ten children without ophthal- 
moscopic signs ; and Richter, quoted by Lawrence, observed 
a similar instance. But the condition of which I have here 
to speak is acute, or idiopathic, night-blindness. 

The patients can see well in good daylight ; but on a very 
dull day, or in the dusk of evening, or by indifferent artificial 
light their vision sinks very much more than that of persons 
with normal eyes. They are then unable to see small objects, 
which are quite plain to other people, and in a still worse light 
they fail even to recognize large objects visible to every one 
else. This peculiar visual defect is due to imperfect adapta- 
tion powxr of the retina, and not to defective light-sense, as 
is sometimes stated. 

Conjunctivitis and xerosis of the conjunctiva are often pres- 
ent in acute nyctalopia (p. 180). Some observers have found 
43 



514 DISEASES OF THE EYE. 

micrococci and bacilli in the conjunctiva in these cases, and 
have regarded these organisms as the cause of the conjunc- 
tival affection. It seems now more probable that they are 
merely secondary to the xerosis. 

The connection between nyctalopia and xerosis conjunc- 
tivae remains to be explained ; but it is likely that they are 
both results of the one cause. 

Acute nyctalopia is often the result of long-continued daz- 
zling by very bright sunlight, or of lengthened exposure to 
bright firelight — e. g., in foundries — and it is probable that 
in many, if not in most instances of this affection defective 
nutrition of the system plays the chief role in rendering the 
patients liable to it. Thus, in scorbutus, acute nyctalopia has 
been frequently seen when the patients have been exposed to 
strong glares of sunlight. 

Treatment consists in protection from light ; in short, in 
complete darkness for a time, and then gradual return to 
ordinary daylight, while the system is to be strengthened by 
careful dietary and suitable tonic medicines. 

Uremic Amblyopia. — This is most commonly seen in 
connection with the nephritis of pregnancy and scarlatina, but 
may occur in any case of uremic poisoning. It is met with 
in acute forms of nephritis in which albuminuric retinitis is not 
so liable to occur. The blindness is usually absolute, and 
may come on suddenly or with a short previous stage of dim- 
ness of vision. It lasts from twelve hours to two or three 
days, and may recover completely, but in some cases a cen- 
tral scotoma remains. 

The oplLtliahnoscopic appearances are negative. 

Treatment can only be directed to the general condition. 

TJie prognosis for vision is good, as it always recovers if 
the patient's life be spared. 

Pretended Amaurosis. — Malingerers rarely pretend total 
blindness of both eyes, and such cases can often only be de- 
tected by constant observation of their actions. 



VARIOUS FORMS OF AMBLYOPIA. 515 

Presence of pupillary reflex is no proof that the patient 
sees, for this would be quite compatible with a cortical lesion 
causing total loss of sight (p. 336). 

The crossed diplopia test (znde infra) may be employed in 
these cases, for if both eyes see, the one with the prism will 
rotate inward for the sake of single vision, while if both eyes 
be blind, of course no such motion will take place. Again, 
if the malingerer's own hand be placed in various positions, 
and he be asked to look at it, he will, in all probability, look 
in some other direction ; whereas a truly blind man usually 
makes a fair attempt at directing his eyes toward his own 
hand. 

Pretended monocular amaurosis can generally be detected 
by the diplopia test. If the malingerer be made to look, 
with both eyes open, at a lighted candle placed some feet off, 
while a prism with its base downward is held before the ad- 
mittedly good eye, he will say he sees two images of the 
light, one over the other. Were he blind of one eye he 
would not see two images. 

Another method — the crossed diplopia test — -consists in hold- 
ing a prism of some ten or twelve degrees with its base outward 
before the pretended blind eye ; when, if it sees, it will make a 
rotation inward for the sake of single vision, an effort which a 
blind eye would not make. 

Alfred Graefe's Method. — In this test the pretended blind 
eye is covered with the surgeon's hand from behind the 
patient, while with the other hand a prism (about ten degrees) is 
held base down before the good eye, so that its edge may pass 
horizontally across the center of the pupil. Monocular double 
vision results, as the rays pass through the upper part of the 
pupil normally, while through the lower part of it they are 
refracted downward by the prism. The double images stand 
over each other. If now the hand which excludes the pre- 
tended blind eye be rapidly removed, while at the same 



5i6 DISEASES OF THE EYE. 

moment the prism is moved upward, so that the entire pupil 
is covered by it, a malingerer will still see double images 
standing one over the other ; for now the diplopia must be 
binocular. 

Harlan's test * consists in placing a trial-frame on the 
patient's nose with a very high + lens, say -f- I4 D, oppo- 
site the good eye, by which means it is excluded from dis- 
tant vision, and a plane glass, or a 0.25 D convex or concave 
lens, which of course would not materially interfere with its 
distant vision, opposite the pretended blind eye. The patient 
then, believing there is much the same kind of glass before 
each eye, will read the test-types, and if it be now desired to 
expose the deception, the pretended blind eye is excluded from 
sight, and the malingerer will then be unable to read the test- 
types. 

Snellen's colored types may also be used for this purpose. 
These types are printed in green and red. If a person be 
really blind of one eye he will, of course, see both the green 
and the red letters with the good eye. But if a green glass 
be held before the good eye, the rays from the red letters will 
be excluded, and he will now only see the green letters ; or 
with a red glass the red letters alone will be seen. A malin- 
gerer may be detected by holding before his admittedly good 
eye a green glass ; and if he now still see the red letters, it 
must be that he does so with the so-called blind eye. 

It is well to have this variety of tests, in order that they 
may be used to corroborate each other. 

Erythropsia (ipuOpoq, red) — Red Vision. — A large num- 
ber of cases of this remarkable affection are on record ; indeed, 
it will have come under the notice of nearly every ophthalmic 
surgeon of any experience. Two-thirds of the cases have 
been subjects of successful cataract operations, whilst the re- 

* Trans. Amer. Ophthal. Soc, Vol. iii, p. 400. 



VARIOUS FORMS OF AMBLYOPIA. 517 

mainder have possessed normal eyes. In some cases the red 
vision remains only a few minutes, and does not again return ; 
whilst ill others it appears every day for a short time, for 
weeks or months ; and, again, in others it continues for sev- 
eral days, and then disappears for good or recurs at inter- 
vals. In the aphakic cases it does not usually appear for 
weeks or months after the removal of the cataract, and in one 
case the interval was two years. During the attacks the 
patients see all objects of a deep red color, and occasionally 
of a purple or violet hue. In no instance is the acuteness of 
vision affected, either during or after the attacks. 

A satisfactory explanation for the affection has not yet been 
offered. It seems probable that it is due to over-excitation 
of the visual nervous apparatus — some believe of the visual 
center, others of the retina — set a going by exposure of the 
retina to strong Hght, along with other favoring circum- 
stances, especially general over-excitement of the body or 
mind. More than this cannot at present be said. Why 
aphakic eyes should be so much more liable to erythropsia 
than eyes which possess their crystalline lenses is an enigma. 

Treatment seems to have but little effect. Protection of the 
eyes from light has not been of use. Bromid of potassium 
internally seems to have done some good in those cases where 
it was tried. 



CHAPTER XVIII. 

THE MOTIONS OF THE EYEBALLS AND 
THEIR DERANGEMENTS. 

The eyeball moves round a point on its antero-posterior axis, 
situated, in the emmetropic eye, 14 mm. behind the cornea, 
and ten mm. in front of the posterior surface of the sclerotic. 
Its motions are effected by means of the six orbital muscles, 
arranged in three pairs, each pair consisting of two antagonistic 
muscles ; thus, the rectus internus and rectus externus are an- 
tagonistic, the former rotating the eye inward, and the latter 
rotating it outward. The two remaining pairs are the recti 
superior and inferior, and the obliqui superior and inferior. 

The primary position of the eyeball is that one in which, the 
head being held erect, the gaze is directed straight forward in 
the horizontal plane. This is the starting-point from which 
the actions of the muscles are considered. 

The rectus externus and rectus internus, lying from their 
origin to their insertion in a plane which corresponds with that 
of the horizontal plane of the eyeball, move the latter on its 
perpendicular axis directly inward and outward, and have no 
other action. 

The plane of the rectus sitperior and rectus inferior does not 
quite correspond with the vertical plane of the eyeball, and 
consequently the axis on which they rotate the globe is not its 
horizontal axis, but one w^hich, passing from within and before, 
backward and outward, forms with the antero-posterior axis an 
angle of 70° (Fig. 130). While, then, their action is mainly 
to rotate the eyeball upward and downward, these muscles 

518 



THE ORBITAL MUSCLES. 



519 



rotate it also somewhat inward. Moreover, the superior rectus 
giving to the vertical meridian of the cornea an inward inclina- 
tion^ or inward wheel-motion "^ of the eye {vide infra), while 
the inferior rectus gives this meridian an outward inclination 
or outward wheel-motion of the eye, the power of these muscles 
over the upward and downward motions is greatest when the 
eye is turned out, for then their axis of rotation coincides most 
closely with the horizontal axis of the globe ; and their in- 
fluence over the wheel-motion is greatest when the eye is 




Fig. 130. 



turned in, for then their axis coincides most closely with the 
antero-posterior axis of the globe. 

The plane of the oblique viiiscles of the eyeball also ap- 
proaches the vertical plane of the eyeball, the axis upon which 
they rotate, the latter passing from within and behind, forward 
and outward, and making, with the antero-posterior axis, an 



* In speaking of the inclination of the vertical meridian of the cornea, it is the 
upper extremity of this meridian which is meant. 



520 



DISEASES OF THE EYE. 



angle of 35° (Fig. 131). The principal action, accordingly, 
of the oblique muscles is to incline the vertical meridian of the 
cornea ; the sup. oblique inclines it inward (wheel-motion in- 
ward), the inf oblique inclines it outward (wheel-motion out- 
ward). In addition to this action, the oblique muscles, re- 
spectively, rotate the eyeball downward and outward (sup. 
oblique), and upward and outward (inf. oblique). It is evident 
that the power of these muscles over the upward and down- 
ward motions of the eyeball is greatest if the eye be turned 
in, and that their power over the wheel-motion is greatest 
when the eye is turned out. 

To sum up, then, the superior oblique and rectus produce 
wheel-motion inward, Avhile the inferior oblique and rectus 

produce wheel-motion 
outward. The action of 
the obliques on the 
wheel-motion is greatest 
when the eye is rotated 
outward, and of the recti 
when the eye is rotated 
Fig. 132. inward. 

In considering the mo- 
tions of the eyeballs, we have to think of the motions of one 
eyeball as associated with those of its fellow ; e. g., the action 
of the internal rectus of the left eye is associated with the action 
of the external rectus of the right eye, in rotation of both eye- 
balls to the right. 

T/ie vertical meridian of the eyes becomes inclined to the right 
or left in different positions of the globe, as was experimentally 
proved by Bonders. 

I. In the primary position, as also when the eyes are turned 
directly inward, outward, upward, or downward, the vertical 
meridians (^, /;, Figs. 132-136) maintain their vertical direction 
(Fig. 132). 





THE ORBITAL MUSCLES. 



521 



2. When the eyes are turned to the left, and upward, the 
vertical meridian of each eye is inclined at the same angle to 
the left (Fig. 133). Wheel-motion to the left. 

3. When the eyes are turned to the left, and dozvjiivard, 
the vertical meridian of each eye is inclined to the right at the 
same angle (Fig. 134). Wheel-motion to the right. 





4. When the eyes are turned to the right, and upward, the 
vertical meridian of each eye is inclined at the same angle to 
the right. Wheel-motion to the right (Fig. 135). 

5. When the eyes are turned to the right, and doivmvard, 
the vertical meridian of each eye is inclined at the same angle 
to the left. Wheel-motion to the left (Fig. 136). 

We shall now consider what muscles are called into action. 





Fig. 136. 

when an indi\idual requires to place his eye in the se\-eral 
principal positions. 

1. In the primary position all the muscles are at rest. 

2. Motion of the eyeball directly outzuard \s effected by the 
external rectus alone, and motion directly inzuard by the 
internal rectus alone. 

3. Motion of the eyeball directly upzc ai'd dind directly dozvn- 

44 



522 DISEASES OF THE EYE. 

ivard is effected chiefly by aid of the sup. and inf. recti. But 
these muscles, acting alone, rotate the eyeball slightly inward, 
and give a certain inclination to the vertical meridian, which 
in this position should be upright. Consequently, in rotation 
of the globe directly upw^ard, the inf. oblique, which rotates 
the eye slightly outward, as well as upward, and inclines the 
vertical meridian outward, must be associated with the sup. 
rectus, in order to counteract in these particulars the tendency 
of its action. In rotation of the eyeball directly downward, the 
inf. rectus must be associated with the sup. oblique, which acts 
antagonistically to this rectus in respect of rotation inward 
and of outward wheel-motion. 

4. Rotation iipzvard and outward is chiefly effected by aid 
of the rectus superior and rectus externus. But the latter 
muscle has no influence over the wheel-motion, while the 
former produces wheel-motion inward. Yet the inclination of 
the vertical meridian is outward in this position ; and therefore 
a third muscle, w^hich will supply this inclination in a high de- 
gree, is required — namel}', the inferior oblique, whose power 
over the wheel-motion of the eyeball is greatest when the 
latter is in this position. 

5. Rotation doivnivard and ojitivard is chiefly effected by 
the rectus inf. and rectus ext. Inasmuch, however, as the 
former inclines the vertical meridian outward, while the latter 
has no influence over it at all, a third force is required which 
will bring about the required inward wheel-motion — namely, 
the sup. obhque, whose influence in this respect is most 
powerful when the eye is in this position. 

6. Rotation upivard and imvard is chiefly brought about b}- 
the rectus superior and rectus internus. But the effect of the 
former upon the inward wheel-motion of the eye would be so 
great as to interfere with parallelism of the vertical meridians of 
the two eyes, that of the other eye not being inclined outward 
in a corresponding degree. A third force, therefore, is required, 



THE ORBITAL MUSCLES. 523 

which will to a certain extent counteract the influence of the 
sup. rectus in this respect, and this is the inf. oblique, which 
in this position of the eyeball has but slight power over its 
wheel-motion. 

7. Rotation dcnvmvard and im^'ard is chiefly the result of 
contraction of the rectus inf. and rectus int. The power of the 
former o\'er the outward inclination of the vertical meridian 
would, in a similar way, be too great, and must be similar!}' 
corrected b}' the action of the superior oblique. 

The Field of Flxatiox. 
The field of fixation contains all the points which the eye 
can successively see or " fix " without movement of the head. 
It can be measured with the perimeter, as in testing the field 
of vision, except that here the patient is made to move the eye 
as far as possible in each meridian, and the limit of each move- 
ment is measured by observing the corneal reflex of a candle- 
flame, or ophthalmoscope mirror, which is moved along the arc 
of the perimeter. The binocular field of fixation contains all 
those points which can be seen as single with the two eyes and 
without movement of the head. According to Landolt * the 
averages give, for movement of one eye, inward 44°, outward 
46°, upward 44°, and downward 50°. 

Strabismus. 
When looking at an}' object with the two e}'es it is neces- 
sar}^ in order to avoid seeing double, that the visual axis of 
the eyes should meet at the point fixed. When this does not 
take place one of the eyes must be in a fault}' position, or, as 
it is commonly termed, it squints. This condition is called 
strabismus, and ma}' arise either from overaction or from 
paralysis of one of the muscles. Strabismus ma}' occur in 

* Landolt and Wecker, Traiie d' Ophthal, Vol. iii, p. 782. 



524 DISEASES OF THE EYE. 

any direction, but vertical and oblique deviations are less 
common than the convergent or divergent forms. 

In order to find out in slight cases which is the deviating 
eye, the patient is made to fix a certain object, and one of the 
eyes, say the left, is rapidly covered with the surgeon's hand ; 
then, if the right eye make no movement, it must have been 
looking at the object ; but if, on covering the right eye, the 
left make a movement in order to fix the object, then this eye 
must be the squinting one. The movement is always in the 
opposite direction to the deviation. For instance, if the eye 
be turned inward too much, it must naturally turn outward to 
fix the object when its fellow is covered. Another good 
method consists in observing the position of the corneal reflex 
when the patient looks at the ophthalmoscope (see Measure- 
ment of Strabismus). But the most delicate test is the char- 
acter of the diplopia, when there is diplopia. 

Apparent strabismus is due to a large angle r (p. 25). In 
this case, as the visual axes are both directed to the point 
fixed, there will be no movement of either eye on covering 
the other, as in true strabismus. 

Paralyses of the Orbital Muscles. 

Loss of power of one or more of the muscles of the eyeball 
is, of course, always to be regarded as a symptom, not as 
itself a disease. 

It may be due to lesions in several different situations, 
namely : i. Lesions situated in the orbit. 2. Basic lesions 
— lesions situated at the sphenoid fissure, and those at the 
base of the skull, between that point and the pons. 3. Pon- 
tile lesions, which may be fascicular — z. e,, involving the 
ocular nerve-fibers in the substance of the pons ; or nuclear 
— i. e., only attacking the nuclei of the nerves in the aqueduct 
of Sylvius and floor of the fourth ventricle. 4. Cerebral 
lesions — lesions above the nuclei, in the internal capsule 



THE ORBITAL MUSCLES. 525 

corona radiata, or cortex. These four classes differ consider- 
ably in their clinical aspect, in their pathologic causes, and in 
their significance for the well-being of the patient. 

The first class — loss of power due to orbital lesions — will 
be referred to in the chapter on Diseases of the Orbit. 

The second class — those due to basic lesions — provides by 
far the largest number of cases of paralyses of the orbital 
muscles. Let us now consider the 

General symptoms of this class. — They include symptoms 
to be found in each of the other classes, i. Diplopia. The 
affected eye being deviated from its correct position, and 
being more or less incapable of associated motions with the 
other eye, the image of the object looked at is not formed on 
identical spots of the retina in each eye, and hence the object 
seems doubled. 2. Indistinct vision. If the paralysis be but 
slight, actual diplopia may not be present, but the double 
images overlapping each other will cause dimness or confusion 
of sight. 3. Giddiness, due partly to the diplopia, and partly to 
faulty projection of the object. By faulty projection is meant 
the false idea of the position of the image in the field of 
vision. 4. Some patients turn the head toward the side of 
the paralyzed muscle, in order to diminish or eliminate the 
diplopia — e. g., if the left ext. rectus were paralyzed the head 
would be turned toward the left ; if it were the left int. 
rectus the head would be turned toward the right. By this 
manoeuver the loss of the action of the affected muscle is less 
felt for those objects which lie straight in the patient's path 
while he walks about ; because it involves a rotation of the 
eye toward the side of the healthy antagonist, in which region 
of the binocular field the diplopia is reduced to a minimum. 
Some patients close one eye to procure single vision. 5. In 
peripheral paralysis it is most common to find only the muscle, 
or muscles, supplied by some one nerve — the third, fourth, or 



526 DISEASES OF THE EYE. 

sixth — affected ; although, of course, exceptions to this are 
not rare, especially where a neoplasm forms at the base of 
the skull. 

In studying a case of paralysis of an orbital muscle, the 
following general principles should be borne in mind : i. The 
defective mobility and the diplopia increase toward the side of 
the affected muscle ; e.g,^ toward the left, if the left external 
rectus be paralyzed ; toward the right, if the left internal 
rectus be paralyzed. 2. The secondary deviation — i. e., the 
deviation of the sound eye while the affected eye fixes — is 
greater than the primary deviation — /. e., the deviation of the 
affected eye while the sound eye fixes ; because the muscle in 
the sound eye, which is associated in its action with the para- 
lyzed muscle in the affected eye — ^-g-, the rect. int. with the 
rect. ext,, must receive a nervous impulse of equal intensity 
to that sent to the weak muscle, and, as the latter requires a 
considerable impulse to excite its action, its associate will be 
overexcited. Let us suppose the left external rectus to be 
paralyzed, and that, shading the right eye with a hand, we 
direct the patient to fix with his left eye an object held some- 
what to his left-hand side ; we may notice, on removing the 
shading hand, that the right eye has been rotated inward to 
an extent far exceeding that of the primary deviation of the 
left eye, and has now to make an outward motion in order 
again to fix the object. 3. The image formed on the retina 
of the affected eye is projected — /. e., seems to the patient to 
lie — in the direction of the paralyzed muscle ; e. g., if the left 
ext. rect. be paralyzed, the image corresponding to that eye 
will be projected to the left of the image belonging to the 
right eye. 

Where the image of the affected eye lies to the correspond- 
ing side the diplopia is termed homonymous, and homony- 
mous double vision always indicates convergence of the visual 



THE ORBITAL MUSCLES. 527 

lines. Figure 137 explains the occurrence of homonymous 
diplopia in convergent strabismus."^ The right eye " fixes " 
the object 0^ and its image falls on the macula lutea m ; but 
the left eye, on account of the paralysis of the external rectus, 
is turned in, and its visual axis lies in the direction ;;/ v, and 
the image of falls to the inner side of the macula lutea at a. 
Now why should this image not be referred to its correct 
position along the line a o ? The reason is that the patient is 




fit) f a 

Left Eye. 



not conscious of the deviation of this eye ; and, having always 
been in the habit of superposing his fields of vision, so that 
the visual axes of the eyes meet at the object fixed, he 
imagines that this is still the case, and that v 111 lies in the 
position of a, and that the macula lutea in is at ni' . But if 
this were the case a would be at a\ and in this position of the 
eye, indicated by the dotted line, images formed at a' to the 

* For the sake of simplicity in the diagram, the effect which rotation of the 

eye has on the nodal point is omitted. 



528 DISEASES OF THE EYE. 

inner side of the macula lutea are projected to the outer side 
of the field, along the line a' o' , and the patient imagines that 
occupies the position o\ as seen with the left eye. 

If we suppose the internal rectus of the left eye to be para- 
lyzed, the image on the retina of that eye falls then to the 
outside of its macula lutea, and must therefore be projected to 
the right of the true position of the object ; this is crossed 
diplopia, and attends divergence of the visual lines. 

Paralysis of the External Rectus of the Left Eye. — If 
this be complete or considerable, it is easy of diagnosis, as 
marked loss of power and motion of the eyeball outward is 
present, and the patient complains of double vision. He keeps 
his head turned to the left, in order to diminish the influence 
of the paralyzed muscle as much as possible. 

If, however, the paralysis be but slight, the patient may not 
complain decidedly of diplopia, but only of indistinctness or 
confusion of sight, especially when he looks toward the left. 
To decide the diagnosis in such a case the double images must 
be examined. A long lighted candle is used as the object to be 
looked at ; and one eye — let us say here the left eye — is 
covered with a bit of red stained-p-lass in order to differentiate 
the images.* The candle is now held on a level with the 
patient's eyes, and straight opposite him, at about three meters 
distance (eyes in primary position), {a) In this position the 
images are seen very close together or overlapping each other, 
both of them upright and on the same level, the red candle to 
the left, the white to the right — /. e., homonymous diplopia := 
convergence. This convergence must be due to paralysis of 
one or other external rectus muscle, but we cannot say at this 
stage of the experiment which of them is affected. (/;) In 
order to determine this point, the candle must be carried from 



* Maddox' Rod Test, described further on, is very suitable here and in the in- 
vestigation of other fonns of ocular palsy. 



THE ORBITAL MUSCLES. 529 

side to side, and the increasing or decreasing distance of the 
images from each other noted. If the candle be carried slowly 
to the right, the patient following it with his eyes while his 
head remains fixed, the images come still closer together, or 
only one candle is seen. But if the candle be carried to the 
patient's left-hand side, the images go further apart, their rela- 
tive positions being maintained. We now know that it is the 
left external rectus which is affected ; because toward the left, 
the direction in which the action of this muscle is most wanted, 
and consequently its loss most felt, the distance between the 
double images increases. The images are erect, as no wheel- 
motion is caused by action of the external rectus, (c) If, how- 
ever, the candle be held to the left and raised 
aloft, the image belonging to the left eye will 
seem to lean away from that of the right eye 
(Fig. 138). The reason of this is that, owing 
to the paralysis of the external rectus, the 
left eye cannot look upward and outward as 
it should, but merely looks upward. The 
vertical meridian therefore remains vertical. ^ig 138. 

But the right eye, which is free to follow the 
candle, looks up and to the left. Its vertical meridian is there- 
fore inclined to the left. That is, the vertical meridians of the 
two eyes converge at the top, which necessitates a divergence 
of the upper extremities of the images. The rotation of the 
right eye in this position is physiologic, and its image is 
therefore judged to be vertical ; while the image of the left 
eye diverging from that of the right, though really vertical, is 
judged to be oblique. An analogous derangement of the 
vertical meridian takes place in the position below and to the 
outside, {d) If the patient be told to direct his gaze specially 
toward the red candle, the distance between the two candles 
will be much greater than if he direct his gaze toward a white 
candle. This is explained by general principle No. 2 (p. 526). 




530 DISEASES OF THE EYE. 

If the patient's good eye be closed, and an object (surgeon's 
finger) be held up within his reach, but toward his left-hand 
side, and he be requested to aim rapidly at it with his fore- 
finger, he will aim to the left of it. The nervous impulse sent 
to his left external rectus, to enable him to turn the eye 
toward the object, is of such intensity as to lead him to fancy 
that the object lies much further to the left than it really does 
(incorrect projection of the field of view) ; for we, to a great ex- 
tent, estimate the distance of objects from each other by the 
amount of nervous impulse supplied to our orbital muscles in 
motions of the eyeball. 

A prism held horizontally before the affected eye with its 
base outward brings the double images closer together ; or, if 
the correct prism be selected, the images will be blended into 
one. 

Paralysis of the Superior Oblique of the Left Eye. — 
This paralysis will be most apparent when a demand is made 
for motion of the eyeball downward and inward, motion in this 
direction being that over which the superior oblique has most 
influence. Yet absolute defect of motion is sometimes difficult 
to detect even in complete paralysis of this muscle, owing to 
vicarious action of the inferior rectus and of the internal rectus. 
Careful examination of the secondary deviation will often be 
successful as to this point, but it is the examination of the 
double images upon which we must chiefly depend for the 
diagnosis. 

(^) In the whole of the field of vision above the horizontal 
plane there is single vision. Below the horizontal plane in 
the median line diplopia appears, the image belonging to the 
left eye standing lower than that belonging to the right, be- 
cause the superior oblique being a muscle which assists in 
rotating the eye downward, the latter, for want of the action of 
this muscle, now stands higher than its fellow (right eye), and 
consequentl}' the image will not fall on its macula lutea, as it 




THE ORBITAL MUSCLES. 531 

does in the right eye, but above it, and will therefore be pro- 
jected below the image of the right eye. The position down- 
ward and inward of the eyeballs is that in which the greatest 
demand is made upon the superior oblique for rotation of the 
eye downward ; therefore it is in this position its want for this 
purpose is most felt, and when the candle is held in this 
position, the vertical distance between the double images is 
greatest, (b) The superior oblique assists also in rotation of 
the eye outward ; therefore loss of its power must commit the 
eyeball to a certain extent to the power of the muscles w^hich 
move it inward, and a rotation in this latter direction (con- 
vergence) takes place, with the result of making the image 
belonging to the left eye stand to 
the left of the image belonging to 
the right eye (homonymous dip- 
lopia), (c) The superior oblique 
inclines the vertical meridian in- 
ward ; therefore, in rotation directly 

downward, loss of its powder com- y"^^ ' ' 

mits the eye to the outward wheel- ^z -^ 
motion imparted to it by the inferior Fig. 139. 

rectus. This gives to the image 

belonging to the left eye an inclination to the patient's right 
hand, (d) The power of the superior oblique to incline the 
vertical meridian inward is greatest when the eye is turned 
downward and outward ; consequently in this respect its 
paralysis will be most felt in this position, and therefore here 
the inclination of its image to that of the sound eye will be 
most marked, {e) A remarkable phenomenon usually noticed 
in this paralysis, and sometimes in paralysis of the inferior 
rectus, and for which a good explanation does not exist, is 
that the image belonging to the affected eye seems to stand 
nearer the patient than that of the sound eye. 

To sum up, then (vide Fig. 139), below the horizontal 



532 



DISEASES OF THE EYE. 



plane there is homonymous diplopia, while the image (A) of 
the affected eye stands on a lower level, is inclined toward the 
other image, and seems to be nearer the patient. Further- 
more : 

(/) In an extreme lower and outer position the image of 
the affected eye may sometimes seem to stand higher than 
that of the sound eye, owing to an excessive outward inclina- 
tion of the vertical meridian, which throws the image on the 
lower and outer quadrant of the retina. 

In order to do away with or to diminish the diplopia the 
patient inclines his head forward, and turns it to the side of 
the good eye. 



.<< 



Fig. 140. 
Paralysis of Left Superior Ob- 
lique. Homonymous diplopia. 
R. Image of right eye. L. Image of 
left eye. 



Fig. 141. 
Paralysis of Right Inferior Rec- 
tus. Crossed diplopia. R''. Image 
of right eye. L, Image of left eye. 



F'or the prismatic correction of the diplopia two prisms will 
be required, one with its base downward in front of the left 
eye to correct the vertical difference, and a second with its 
base outward in front of the right eye to correct the lateral 
difference. 

To make the diagnosis between the foregoing paralysis and 
paralysis of the right inf rectus (in which the diplopia is 
also below the horizontal plane only, and the false image 
lower than the true one and inclined toward it) it has merely 
to be remembered that there is here crossed, instead of 
homonymous, diplopia, because the superior oblique, which 
now chieflv effects the downward motion of the eyeball, turns 



THE ORBITAL MUSCLES. 



533 



it at the same time somewhat outward. The figures 140 and 
141 will assist in this explanation. 

Paralysis of the Internal Rectus, Superior Rectus, In- 
ferior Rectus, Inferior Oblique, and Levator Palpebrse. — 

Complete paralysis of all the branches of the third nerve 
produces a remarkable appearance. The upper lid droops 
(ptosis), the pupil is semi-dilated and immovable, the power 
of accommodation is destroyed, and the eyeball is often slightly 
protruded, owing to the backward traction of the recti being 
lost to it. Motion inward exists but to a slight degree, and 




Fig. 142 



motion downward is effected only by aid of the superior 
oblique, and is accompanied by marked inward wheel-motion. 
If the paralysis be of some little standing, the external rectus 
obtains rule over the eyeball, and rotates it permanently out- 
ward. 

The diagnosis, then, in cases of complete paralysis of all 
branches of the nerve, is easily made ; but not so, sometimes, 
if the paralysis be only partial. The examination of the double 
images, then, is of value. If (see Fig. 142) the left third 
nerve be partially paralyzed in all or most of its branches, there 



534 DISEASES OF THE EYE. 

will be crossed diplopia, either in the whole of the field of 
vision, for want of power in the internal rectus, or toward 
the patient's right at the least, and the lateral distance between 
the images will increase as the visual object is carried further 
toward the right. When the visual object is held aloft the 
left eye will remain behind, for want of the action of both of 
the muscles which turn the eye upward, and consequently in 
this position its image will stand, not only to the right of, but 
also above that of the right eye ; while, when the visual object 
is held below the horizontal plane, the eye will, owing to 
paralysis of the inferior rectus, remain higher than the right 
eye, and consequently its image will appear to be lower than 
that of the right eye. It will, moreover, be inclined toward 
the latter image, in consequence of the inward wheel-motion 
imparted to the eye by the superior oblique. 

When in each eye some branches of the third nerve are 
paralyzed, the diagnosis is often extremely complicated. The 
ptosis, however, which is nearly always present, and is readily 
recognized, and the paralysis of the sphincter iridis (mydriasis) 
and of accommodation, which often exist, and are also easily 
observed, give valuable aid. Moreover, any loss of motion 
upward must be due to paralysis of the third nerve ; but if 
there be loss of motion downward, the differential diagnosis 
between paralysis of the inferior rectus and of the superior 
oblique has to be made. For this see the paragraph on 
paralysis of the latter muscle. 

As may be imagined from the foregoing, it is often difficult 
in practice to keep clearly before one's mind the different 
actions of the orbital muscles, and from the character of the 
diplopia to deduce the paralysis which may be present. An 
aid in this respect has been provided by Dr. Louis Werner,* 
by means of two diagrams (Figs. 143 and 144). 

* ophthalmic Review, March, 1886. 



THE ORBITAL MUSCLES. 



535 



The form of diplopia which characterizes paralysis of each 
muscle is expressed by the position of the dotted line bearing 
the name of the muscle. The dotted lines represent the 
"false images," the continuous lines the "true images." "^ 

In the case of the recti (Fig. 143) the false images inclose 
a lozenge-shaped space situated between the true ones, w^hereas 
in the case of the oblique muscles (Fig. 144), the true images, 
which for the sake of simplicity are combined in one line, lie 
between the four "false images," which diverge from one 
another so as to form an X. It will also be noted that the 
dotted lines extend upward and doAvnward beyond the others, 
indicating respectively that the 
" false images " are higher or 
lower than the true ones. 
Another fact which the dia- 
grams indicate is that in the 
case of the muscles represented 
in the upper halves of the fig- 
ures, the diplopia occurs in the 
upper part of the field of fixa- 
tion, or, in other words, in up- 
ward movements of the eyes. 
A similar rule holds good with 
regard to the lower halves. 

The method of using the diagrams will be better under- 
stood by taking a particular muscle as an example. Suppose, 
for instance, that we wish to know what kind of diplopia re- 
sults from paralysis of the left inferior rectus, it is simph^ 
necessary to look at the left inferior portion of figure 143 
(recti), which gives the diplopia. If we analyze this, we find : 
I. That the diplopia is ''crossed,'' for the false image corre- 



Left 
Sup. Beet 

Left 
h^f. Reet 




Bfyht 
H/p. Reel. 

Ricjlit 
Inf. Beet 



Fig. 143. 



*The " false image " corresponds to the affected eye, and the "true image " 
to the sound eye. 



536 



DISEASES OF THE EYE. 



spending to the left eye is on the right of the true image — i. e., 
the right image corresponds to the left eye. 2. That the 
false image has its upper end inclined tozvard the true one. 
3. That the false image is lozver than the true one, for the 
dotted line extends lower than the other one. 4. That the 
diplopia occurs in doivnward movements of the eyes, for it is 
in the lozver half of the diagram that the false image lies. 

The same method applies to the other recti ; the diplopia 
for the right tipper rectus is found in the right upper quadrant, 

and so on for the rest. 

The same rules also apply to 
the obliques (Fig. 144), with 
one difference. The recti 
move the eye in the direction 
indicated by their names, the 
superior moving it upward 
and the inferior downward ; 
but in the case of the obliques 
the reverse takes place, the 
superior oblique moving the 
eye downward and the infe- 
rior upward. Therefore, for 
the superior obliques we must 
figure 144, and for the inferior 



Left 
L^f Obi. 



Right 
Inf. Obi. 



Left 
Sap. 061. 



Right 
Sup. Obi. 



Fig. 144. 



look at the lozver half of 
obliques at the upper part. 

This is an extremely simple method. By bearing the figures 
in mind it is possible to tell immediately what kind of diplopia 
would result from paralysis of any one of these muscles, and 
conversely, given the diplopia, to determine to which muscle 
it is due. 

The causes of peripheral paralyses of orbital muscles are 
chiefly of rheumatic or syphilitic nature. 

Rheumatic paralysis, to which the external rectus is speci- 
ally prone, will be noted if there are symptoms of general 



THE ORBITAL MUSCLES. 537 

rheumatism, or if there is a history of exposure to cold or 
wet immediately preceding the attack. 

Syphilis will be suggested as a cause if there be a specific 
history, and that other causes can be excluded. Peripheral 
paralyses of the orbital muscles due to syphilis are amongst 
the later symptoms of the disease, and may depend on 
exostoses or gummata at the base of the skull, or to syphilitic 
neoplasms, or meningitis, in the course of the nerve. The 
third nerve seems to be particularly liable to be attacked by a 
solitary gumma at the base of the skull, especially at the 
sphenoid fissure, ptosis being commonly the first symptom. 

Other neoplastic growths can, of course, cause these paral- 
yses in the same way. 

Prognosis. — In peripheral paralyses recover}' is very fre- 
quent ; much, however, depending on the nature of the lesion. 
In cases where a cure is not effected, the antagonist muscle 
often becomes contracted, and the eye is then rotated per- 
manently and excessively in the corresponding disection. In 
cases of old standing, a permanent contraction of the muscles 
of the neck may be brought about, from the inclination of the 
head which the diplopia has obliged the patient to adopt. 

Treatment. — In these cases, the medical treatment consists 
in drugs suitable to the fundamental disease (rheumatism, 
syphilis, etc.). Local depletion at the temple by the artificial 
leech in the early stages, and galvanism later on, may be em- 
ployed with advantage. The most common method of apph^- 
ing galvanism is through the closed lid ; but it is probable that 
the episcleral method — i.e., with the electrode placed directly 
over the muscle — is more effectual ; and by the aid of cocain 
this can now be done painlessly. Dr. Buzzard's method '^ 
seems to be a very admirable one. He applies a moistened 
plate rheophore to the nape of the patient's neck, and connects 

* Trans. Ophth. Soc, Vol. ix, p. 191. 
45 



538 DISEASES OF THE EYE. 

it with one pole of a Leclanche battery. He then takes the 
other rheophore, well wetted, in his left hand, and, securing 
good contact with the skin of his palm, applies the index finger 
of his right hand to the patient's globe in the situation of the 
various external muscles of the eye. The finger is covered 
with a single thickness of well-moistened muslin, and the con- 
junctiva should be previously rendered insensitive by cocain. 
The strength of the current advised is from 1.5 to 2 milliam- 
peres, and the alternate application and lifting of the finger, by 
closing and opening the circuit, gives rise to a feeling of a 
slight electric shock in the terminal point of the finger. The 
operator should first test the strength of the current upon the 
patient's cheek. The point of the finger thus employed acts 
as a sentient rheophore, and can be applied with nicety and 
delicacy to various parts of the eye, the operator being con- 
stantly aware, by the feeling in his finger, of the strength of 
the current employed. 

Passive orthopedic treatment * occasionally gives a rapid 
and brilliant result, while, again, it is useless. It is performed 
as follows : The conjunctiva at the corneoscleral margin, near 
the insertion of the paralyzed muscle, is seized with a forceps, 
and the eyeball is drawn in the direction of the muscle, and as 
far as possible beyond its ordinary limit of contraction, and back 
aeain. These movements are continued for about a minute 
once a day, and cocain "is used. 

Prismatic glasses may be used, either to eliminate the 
diplopia or to excite the weak muscle to exert itself. In the 
former case, the glass selected must completely neutralize the 
diplopia ; but as it can do so only for one position of the eyes, 
prisms are rarely employed in this way. In the latter case, a 
prism slightly weaker than that sufficient to completely neutral- 

* First proposed by Prof. J. Michel, Klin. Monatsbl. f. Aiigenheilk., 1887, p. 
373. 



THE ORBITAL MUSCLES. 539 

ize the diplopia is selected, in order that, with a little effort, the 
weak muscle may be enabled to bring about single vision, and, 
this effort having been successfully maintained for some days, 
a still weaker prism is then prescribed, and so on. 

It is very important for the patient's comfort while awaiting 
his cure — unless a cure by prisms as above described is being 
attempted — that the affected eye should be covered so that the 
distressing double vision may be obviated. 

Surgical treatment is justifiable only when other means 
have failed to restore muscular equilibrium. If the deviation 
amount to three or four mm., tenotomy of the antagonistic 
muscle, with subsequent tenotomy of the associate muscle in 
the other eye, will be sufficient ; but if the deviation amount to 
five or six mm., advancement of the paralyzed muscle, in ad- 
dition to the tenotomy, may be required. This surgical treat- 
ment applied to the internal and external rectus gives satisfac- 
tory results ; but in the cases of the superior and inferior recti 
it is not so satisfactory, while the oblique muscles should not 
be operated on. 

A peculiar and rare form of peripheral or basal paralysis 
is intermitting paralysis of one third nerve, for which 
Charcot suggested the name of ophthalmoplegic migraine. 
The patients are generally children or young adults, who 
usually suffer from headache on the side corresponding to the 
paralyzed eye, and sometimes from vomiting. The paralysis 
may be complete or partial, and the attack varies in its dura- 
tion from a few days to a few months. Some cases are purely 
periodic — i.e., in the intervals between the attacks of paralysis 
all the muscles supplied by the third nerve act in a completely 
normal manner, while in other cases those muscles, or some 
of them, do not completely recover their functions in the in- 
tervals. We are as yet quite in the dark as to the cause of 
these periodic paralyses of the third nerve. Some hold that 
the purely periodic cases are of a functional nature, possibly 



S40 DISEASES OF THE EYE. 

hysteric or reflex, and that the periodically exacerbating cases 
alone are due to a lesion of the root of the nerve of an unde- 
fined kind at the base of the skull, while others are of opinion 
that both forms depend upon a diseased process at the base. 
In three cases in which an autopsy was made, there was disease 
of the trunk of the nerve at the base of the skull. 

In intermitting pa.vsi\ysis, the p^oo-nosis of the purely periodic 
form is favorable, inasmuch as the attacks in the course of 
time become fewer and less severe, until, finally, they cease 
entirely. In the exacerbating form, the prognosis for complete 
recovery is less favorable. Out of 26 cases collected by 
Darquier * only one patient died from a cerebral cause. 

In view of the obscurity which still surrounds the causation 
of these intermitting paralyses, their ti^eatmeiit must consist, in 
each case, in the relief of any general dyscrasia or concomitant 
symptoms which may be present. 

The third class of paralyses of orbital muscles above 
enumerated — those due to lesions of the nuclei of the orbital 
muscles in the aqueduct of Sylvius and floor of the fourth 
ventricle — are known by the term 

Ophthalmoplegia Externa, and also as Nuclear 
Paralysis. — The first of these terms was originally employed 
to denote those remarkable cases in which all, or nearly all, of 
the orbital muscles of both eyes are paralyzed, while the in- 
traocular muscles often remain intact. There can be no doubt, 
however, that these cases do not differ in their nature from 
many of those in which, in one eye, several orbital muscles 
supplied by different nerves — c.g.^ third and fourth — are wholly 
or partially paralyzed ; or where all the orbital muscles in one 
eye are wholly or partially paralyzed ; or where in each eye 
muscles supplied by the same nerve — e.g., both sixth nerves — 



* Annales cf Oculist., October, 1893, p. 257. I'his paper contains a complete 
bibliography. 



THE ORBITAL MUSCLES. 541 

are wholly or partially paralyzed ; for such cases are often 
mild forms of the disease, or else stages in its development. 
At one time it was considered essential for the diagnosis that 
the intraocular muscles should retain their functions, but cases 
occur in which the sphincter iridis and ciliary muscle are 
paralyzed. 

When these two latter muscles alone are paralyzed the 
condition is called ophthalmoplegia interna. When both they 
and groups of orbital muscles are paralyzed, the terms ophthal- 
moplegia interna et externa, or ophthalmoplegia universa, are 
employed. 

The term nuclear paralysis indicates any orbital paralysis 
due to a lesion of the nuclei of the orbital nerves in the pons, 
and ophthalmoplegia externa comes within this category. 

Ptosis, even in cases of complete binocular ophthalmoplegia 
externa, is often incomplete, and it is remarkable that in some 
chronic cases, without any improvement in the condition itself, 
the diplopia, which was at first present, quite disappears. 

Occurrence and Progress. — The condition may be congenital 
or may make its appearance soon after birth, and may remain 
permanently without becoming complicated with any further 
disturbance. Congenital ptosis, which is frequently combined 
with loss of power in the superior rectus, and is usually bin- 
ocular, is of this nature. But nuclear paralysis is more com- 
monly seen as an acquired condition in childhood or in adult 
life, either in an acute or chronic form. Marked cerebral 
lethargy is often seen with both forms, and the tendon reflexes 
may be defective. 

Acute nuclear paralysis is due either to an acute inflamma- 
tory process in the nuclei — comparable to the process which 
produces poliomyelitis anterior acuta, and hence it is called 
by Byrom Bramwell poliomyelitis acuta — or to hemorrhagic 
lesions. 

The acute inflammatory cases are apt to have a sudden 



54-2 DISEASES OF THE EYE. 

onset, attended with fever, headache, vomiting, and convul- 
sions, which may subside after a few days, leaving only the 
ophthalmoplegia behind ; and this, too, after a lengthened 
period, may undergo cure, partial or complete. Sometimes 
these attacks are complicated with paralysis of the facial nerve, 
or the diseased process may extend to the spinal cord, and the 
symptoms of acute poliomyelitis become developed ; or, again, 
acute bulbar paralysis may come on. 

Acute peripheral neuritis of the ocular nerves, which is 
sometimes seen in cases of alcoholic poisoning, may be con- 
founded with acute nuclear palsy. The symptoms of the two 
states are the same, except that in the case of peripheral 
neuritis there are no head symptoms at the commencement. 

The onset of acute hemorrhagic ophthalmoplegia is sudden, 
but unattended by headache, vomiting, or convulsions. It 
takes different courses. Sometimes it is rapidly fatal ; again, 
it goes on to softening of the nuclei, and becomes chronic ; 
while, again, it undergoes a slow cure. 

It is extremely probable that to this hemorrhagic class the 
paralyses of orbital muscles belong, which sometimes follow 
on an attack of diphtheric sore throat. These paralyses ap- 
pear in from one to six weeks after the outbreak of the primary 
affection. The latter need not have been of a severe kind ; 
indeed, sometimes patients are unaware that they have had a 
sore throat. These diphtheric paralyses always recover in 
the course of some weeks. 

In diabetes, paralyses of orbital muscles are not very un- 
common, and are probably to be classed as nuclear. The 
same may- be said of orbital paralyses in lead-poisoning and 
in epidemic influenza (" la grippe "). Other causes are cold, 
poisoning by nicotin, sulphuric acid, carbonic oxid, and tainted 
meat. 

The prognosis in all these instances is favorable. 

Chronic nuclear paralysis (chronic polienccphalitis superior. 



THE ORBITAL MUSCLES. 543 

of Wernicke) is much more common than the acute form. It 
depends on a degenerative atrophy of the nerve nuclei, analo- 
gous to that which occurs in progressive muscular atrophy 
and in chronic bulbar paralysis. The onset is gradual, the 
loss of power in the muscles being at first very slight, but 
ultimately complete paralysis of the affected muscles results. 
There is no fever, nor any cerebral symptom. The condition 
may become associated with chronic bulbar paralysis, with 
progressive muscular atrophy, or with locomotor ataxia. But 
this is not so liable to occur in infants as in adults. 

In some cases there may be partial paralysis of the orbicu- 
laris palpebrarum,* which, according to Mendel, is innervated 
from the third nerve nucleus through the facial nerve, along 
with other muscles of the oculo-facial group (frontalis and 
corrugator supercilii). 

Coarse lesions, especially tumors of the pons and of its 
neighborhood, which press on it, may produce orbital paralyses 
closely simulating those due to nuclear lesions. But here the 
paralysis is only one of the symptoms in the case, which are 
likely to include headache, vomiting, optic neuritis, hemian- 
opia, hemiplegia, etc. Softenings, patches of disseminated 
sclerosis, and internal hydrocephalus with over-distention of 
the aqueduct of Sylvius, are other lesions which may give rise 
to similar orbital paralyses, but which cannot be regarded as 
true nuclear ophthalmoplegia. The mode of onset and the 
concomitant symptoms of each case must serve as our guides 
in arriving at a diagnosis, which will sometimes be difficult 
enough. 

Conjugate lateral paralysis of the eyes is a symptom which 
may be caused by a lesion in the pons. We believe that the 
voluntary motor impulses, coming down from the cortex to 
produce associated lateral motions of the eyeballs — /. c, action 

* Hughlings Jackson, Lancet^ July 15, 1893. 



544 DISEASES OF THE EYE. 

of the external rectus of one eye along with action of the in- 
ternal rectus of the other eye — first reach the nucleus of the 
sixth nerve, and then pass on, through fibers called the 
posterior longitudinal bands, under the corpora quadrigemina, 
and join with the fibers of the opposite third pair for the 
supply of the internal rectus of that side. The sixth pair of 
one side supplies in this way the external rectus of its own 
side, and to a slight extent the internal rectus of the opposite 
side ; and it is quite probable that similar decussations may 
exist in the nerve supply of other orbital muscles. Hence a 
lesion at, let us say, the left sixth nerve nucleus would paralyze 
the conjugate lateral motions of the eyes toward the left side ; 
and there would, in consequence, be conjugate lateral deviation 
of the eyes toward the right — the eyes look away from the 
lesion. In conjugate paralysis, or deviation, whether due to a 
pontile lesion, or, as in a later paragraph, to a cerebral lesion, 
the combined action of the internal recti for the purpose of 
convergence of the eyes is retained. 

Paralysis of the orbital muscles from nuclear disease may 
occur in locomotor ataxia, disseminated sclerosis, general 
paralysis, and, more rarely, in exophthalmic goiter and severe 
multiple neuritis. 

Fascicular paralyses are mainly distinguished by tlie presence 
of other .symptoms due to involvement of neighboring struc- 
tures, and are rarely symmetric. Vertigo is common with 
third-nerve paralysis, owing to implication of the red nucleus 
in the tegmentum which is connected with the superior pe- 
duncle of the cerebellum. 

Cerebral paralysis of orbital muscles form the fourth and 
last of the classes enumerated. They include all the orbital 
paralyses due to lesions above the nuclei — i. e., in the cortex, 
corona radiata, or internal capsule. They are usually asso- 
ciated with other symptoms which aid us in localizing, more 
or less accurately, the lesions which cause them. These 



THE ORBITAL MUSCLES. 545 

paralyses are always physiologic, associated, or conjugate, as 
they are variously and with equal correctness termed — they 
are, in short, paralyses of motion rather than of muscles. 
Conjugate lateral paralysis — loss of power of motion of the 
eyes to one side or to the other, while the power of conver- 
gence of the optic axes is retained — is by far the most common 
form of this symptom. We do not as yet know where the 
cortical center for the associated lateral motions of the eye is 
situated."^ But even if we did know its position, it is not likely 
that much would be gained so far as clinical localization of the 
cerebral lesion is concerned ; for this center, wherever it may 
be, is extremely sensitive, and is apt to be thrown out of gear 
by lesions of many different parts of the cortex. Conjugate 
deviation is, in short, very apt to be a distant symptom, 
especially in cerebral hemorrhage, when it is often accom- 
panied by a rotation of the head in the same direction, and 
lasts only a short time. Moreover, it is thought that, when 
this center may happen to be actually involved in the lesion, 
its function, being largely bilateral, is rapidly taken up by the 
opposite hemisphere ; and hence, even when conjugate lateral 
deviation plays the part of a direct cortical symptom, it can 
never be recognized as such, owing to its evanescent character. 
In paralyzing lesions, the deviation of the eyes is of course 
toward the side of the lesion — the eyes look at the cerebral 
lesion, as Prevost has expressed it — while in irritating lesions 
the spasm of the affected muscles causes the deviation to be 
from the side of the lesion. These conditions are the reverse 



* The center has been placed by various authors in the inferior parietal lobule 
(Wernicke, Henschen, Munk, etc.), and in the second frontal convolution 
(Ferrier, Horsley, and Beevor). But stimulation of the centers of vision (occipi- 
tal lobe) has also been found to produce conjugate movements (Schaefer, Munk), 
and these have been regarded as reflex by some ; but Knies holds that the visual 
center contains the motor center as well. Moreover, it is stated that the visual 
cortex contains motor pyramidal cells. 
46 



546 DISEASES OF THE EYE. 

of what happens in conjugate lateral deviation due to lesions 
in the pons (p. 543), and we are thus enabled to differentiate 
between lesions in the two positions. 
There are four possible cases : 

^ , , , . f Destructive. Eyes turned away from paralyzed side. 

Cerebral lesions. J^ ■' , 

l Irritative. " " toward convulsed side. 

Ti ,., 1 . f Destructive. " " toward paralytic side. 

Pontile lesions. ; r j 

\ Irritative. " " away from convulsed side. 

The cerebral cases show that the center for associated move- 
ments is on the opposite side of the brain — e. g., in movements 
of eyes to the left, the left external rectus and right internal 
rectus are innervated by the right hemisphere of the brain ; 
consequently a destructive lesion here would produce paralysis 
of the left side of the body and of the associated movements 
of the above orbital muscles, and therefore the eyes would be 
drawn to the right by their opponents ; /. e., away from the 
paralyzed side. A destructive lesion of the right side of the 
pons would also, of course, produce paralysis of the left side 
of the body ; but, involving the right sixth nucleus, it would 
cause paralysis of the associated movements of the right ex- 
ternal rectus and left internal rectus, and consequently the 
eyes would be drawn to the left by the opponents — /. e., 
toward the paralyzed side. 

The reverse of the foregoing would occur in irritative lesions. 
Figure 145 will serve to illustrate the points referred to. 

A destructive lesion at 12, the right cortical center, involving 
also motor centers of the body, would cause left hemiplegia ; 
and, since the external rectus of the left eye and internal 
rectus of the right eye would be paralyzed, the antagonists 
would turn the eyes to the right ; /. c, away from the 
paralyzed side. A destructive lesion of the right side of the 
pons, also producing left hemiplegia, if it involve the sixth 
nucleus, will produce paralysis of the external rectus of the 
right eye and of the internal rectus of the left eye, and then 



THE ORBITAL MUSCLES. 



547 




the antagonists would turn the eyes to the left; /. e., toward 
the paralyzed side. It is easy to see how irritative lesions 
would produce exactly the opposite effects. 

Hemianopia interferes to a certain extent with the conjugate 
movement toward the affected side, 
in so far as this is guided by visual 
impressions. According to Knies, 
the difficulty in reading in right 
hemianopia is mainly due to this 
cause. 

It seems important here, even 
at the risk of some repetition, to 
direct special attention to 

The Localizing Value of 
Paralyses of Orbital Muscles 
in Cerebral Disease. — Paralysis 
of the Third Nerve. — As regards 
this nerve, we are struck with the 
fact that ptosis, partial or com- 
plete, may be present as a focal 
symptom in cortical lesions — cere- 
bral ptosis, as it is called — without 
any other third-nerve branch being 
paralyzed. That a separate cortical 
center for this branch of the third 
nerve exists, and that it innervates 
the muscle of the opposite side, is 
very probable. The existence of 
such a center would not be incon- 
sistent with the view that, as regards the motions of the 
eyeballs, associated centers alone are present ; for, although 
as a rule the elevators of the lids are associated in their 
motions, yet by an effort of the will most people can throw 
one of them into motion separately, or more than the other. 



liG. 145. 

I. Left external rectus. 2. Left 
internal rectus. 3. Right in- 
ternal rectus. 4. Right ex- 
ternal rectus. 5. Nucleus left 
third nerve. 6. Nucleus right 
third nerve. 7, 8. Posterior 
longitudinal bands from sixth 
nerve to opposite third nerve. 

9. Nucleus left sixth nerve. 

10. Nucleus right sixth nerve . 

11. 12. Left and right cortical 
centers. An impulse starting 
from 12 would travel down to 
9, and produce an associated 
movement of the eyes to the 
left. 



548 DISEASES OF THE EYE. 

No doubt the power to voluntarily innervate one levator and 
orbicularis alone varies in different individuals, and in many 
persons the levator centers are practically associated centers, 
and probably this is the reason why cerebral ptosis is rather 
rare. The position of this center is still an open question, but 
it is believed to be situated in front of the upper extremity of 
the ascending frontal convolution close to the arm center. 

Ptosis, then, has no value as indicating the locality of a 
lesion in the cortex ; but it may be of use in distinguishing 
a cortical lesion from one situated elsewhere in the brain, for 
monolateral ptosis, as the only focal symptom, occurs with 
cortical lesions alone. 

It is probable that ptosis, as the result of a cortical lesion, 
is a distant symptom in not a few of the cases where it is 
present. 

Ptosis on the side of the lesion has occasionally formed a 
symptom in disease of the pons without paralysis- of the other 
branches of the third nerve, except, sometimes, in so far as 
conjugate deviation {vide siiprci) is concerned, and without the 
third nerve being involved in the lesion. 

Again, ptosis, by forming a factor of a crossed paralysis, 
may serve to localize a lesion in the crus cerebri. When the 
third nerve is paralyzed by a lesion in this situation, it is the 
rule to find it paralyzed as a whole, but paralysis of only some 
of the third-nerve branches may be produced by a lesion of 
the cerebral peduncle, and the branch to the levator palpebrae 
seems to be the one most frequently implicated alone. 

In order, now, to complete this subject of ptosis as a focal 
symptom, I must refer to a rare form of it which has been de- 
scribed by Nothnagel, and which does not depend on a lesion 
of the third nerve. It may be called sympathetic or pseudo- 
ptosis, and is accompanied by other eye-symptoms, as well as 
by symptoms of vasomotor paralysis of one side of the body, 
such as elevation of temperature, and redness and edema of 



THE ORBITAL MUSCLES. 549 

the skin. In these cases, this author says, there is (i) appar- 
ent ptosis on the paralyzed side, owing to the contraction of 
the palpebral aperture, but the lid can be raised ; (2) contrac- 
tion of the pupil on the same side ; (3) a shrinking back of the 
eyeball into the orbit, so that it seems to have become smaller ; 
(4) an abnormal secretion of thin mucus from the correspond- 
ing nostril, of tears from the affected eye, and of saliva from 
the corresponding side of the mouth. Nothnagel states he 
has found this train of symptoms in lesions of the corpus 
striatum. 

A common sign of disease of the crus cerebri is what is 
known as crossed hemiplegia. Paralysis of the third nerve on 
the side of the lesion, with hemiplegia, hemianesthesia, often 
facial, and sometimes hypoglossal, paralysis of the opposite 
side of the body is a frequent form of it. The lesion may 
implicate all the branches of the third nerve or only some of 
them. But the localizing value of crossed hemiplegia, as 
Hughlings Jackson long ago pointed out, depends chiefly on 
the hemiplegia and paralysis of the cranial nerve coming on 
simultaneously. If they occur at different times they may be 
due to two distinct lesions, neither of which may be in the 
crus ; for the hemiplegia might be due to a lesion in the hemi- 
sphere, and the third-nerve paralysis to a basal lesion of earlier 
or later date. Yet a few cases have been observed where, 
with a lesion in the cerebral peduncle, the third-nerve paralysis 
preceded the hemiplegia by a considerable inter\al. 

That basal lesions are by far the most frequent cause of 
paralysis of the third nerve is beyond a doubt ; and here it is 
usual, but not constant, to find it paralyzed in all its branches. 
The diagnosis to be made when direct symptoms are being 
considered is, for the most part, between a lesion in the crus 
and a lesion at the base. We cannot pretend to be able to 
make this diagnosis with certainty in all cases. Complete 
paralysis of every branch of the third nerve without any other 



550 DISEASES OF THE EYE. 

paralysis is almost always basal ; so also are those cases in 
which, where there is hemiplegia, it is slight as compared with 
the degree of the third-nerve paralysis ; and those cases, too, 
to which I have already referred, where there is an interval 
between the onset of the paralysis of the extremities and of 
the third nerve, are apt to be basal. Of course there may be 
such a combination of paralysis of the other cerebral nerves 
with that of the third nerve as to leave no doubt with reference 
to the basal position of the lesion. 

The third nerve may be paralyzed by lesions in the inter- 
peduncular space, in which case the paralysis may be partial 
(ptosis alone, or abolition of upward and downward motion 
only *) or complete, single or double. When both nerves are 
affected, there is generally also paralysis of the other orbital 
nerves, or of the facial nerve ; and hemiplegia or hemianopia 
may also be present. 

Thrombosis of the cavernous sinus invariably produces 
paralysis of the third nerve, but all the orbital nerves, as well 
as the fifth and the optic nerves, may also be involved, giving 
rise to complete immobility of the eye, with loss of conjunc- 
tival and corneal sensation. The pupil is usually contracted 
at first, but later on dilates. The venous obstruction causes 
exophthalmos, edema of the lids, and chemosis. Congestion 
papilla is sometimes found. The general symptoms are rigors, 
high temperature, and vomiting. Its principal causes are in- 
fective inflammation of the orbital cavity ; erysipelas of the 
face ; infective inflammation in the buccal, nasal, and pharyn- 
geal cavities, and of the body of the sphenoid ; and ex- 
tension of thrombosis of the sinuses from purulent otitis. 
The thrombosis in more than half the cases spreads to the 
other side through the circular sinus. When the invasion 
occurs from the intracranial direction, pain in some or all of the 

* Uhthoff, von Graefe' s Archiv, xl, i. 



THE ORBITAL MUSCLES. 551 

branches of the first division of the fifth nerve is usually an 
early symptom. 

Third-nerve symptoms, in addition to those included under 
the headings conjugate deviation, or paralysis, and ptosis, are 
sometimes distant symptoms. Tumors of the cerebral hemi- 
spheres, more particularly if accompanied by violent general 
head symptoms, indicating probably high intracranial pressure, 
are the lesions most apt to produce these distant third-nerve 
symptoms. As a rule, the slighter the general cerebral symp- 
toms are, the more likely are the third-nerve paralyses to be 
direct symptoms. This rule, indeed, applies to other as well 
as to third-nerve focal symptoms. 

Paralysis of the fourth nerve, when combined with paralysis 
of other motor eye-nerves, is difficult to recognize ; and conse- 
quently in such cases it supplies but little aid for localization. 
Solitary paralysis of this nerve as a symptom of cerebral focal 
lesion is extremely rare. Nieden has placed a case on record 
in which paralysis of one fourth nerve was the only focal 
symptom to which a tumor of the pineal gland, of the size of 
a walnut, gave rise. But the isolated fourth-nerve paralysis 
is more apt to be produced by a basal lesion. Pfungen * has 
pointed out that, in meningitis, exudation in the space between 
the corpora quadrigemina and the splenium of the corpus 
callosum may implicate the fourth nerves in the valve of 
Vieussens, and believes it is prone to do so in tubercular 
meningitis. In combination with paralysis of the third nerve 
it speaks for a lesion in the cerebral peduncle, extending back 
to the valve of Vieussens, and has, I believe, been utilized by 
Meynert \\\ this sense. 

When paralysis of the sixth nerve occurs as the only focal 
sign, it is probably due to disease at the base, or it is a distant 
symptom. There is no cranial nerve so liable to provide a 

* Wien. Med. Bldtt., Nos. 8-1 1, 1883. 



552 DISEASES OF THE EYE. 

distant symptom as the sixth. Gowers refers this HabiHty to 
the lengthened course these nerves take over the most promi- 
nent part of the pons, which renders them readily affected by 
distant pressure. One or both nerves may in this way be 
paralyzed. Wernicke states that sixth-nerve paralysis is most 
apt to be present as a distant symptom when the lesion, 
especially a tumor, is situated in the cerebellum, differing in 
this way from the third nerve, which, as I have said, is more 
likely to give distant symptoms with a lesion in the cerebral 
hemisphere. 

Paralysis of the sixth nerve, simultaneous in its onset with 
hemiplegia of the opposite side of the body, indicates a lesion 
in the pons, usually a hemorrhage, on the side corresponding 
to the paralyzed nerve. We know that the fifth and facial, 
and sornetimes the auditory, spinal accessory, and hypoglossal 
nerves, may all, in varying combinations, form one of the 
elements in a crossed paralysis from a lesion in this position ; 
but if special localizing value is to be given here to the partici- 
pation of any one cranial nerve, that nerve is the sixth. The 
paralysis of this nerve, simultaneously with palsy of the oppo- 
site side of the body, while other conditions point to an intra- 
cranial lesion, speaks then almost certainly for pontile disease. 

Basal paralysis of the sixth nerve is frequently double, 
especially in syphilis. Fracture of the apex of the petrous 
portion of the temporal may also cause it. 

Paralysis of the facial with the sixth is not an uncommon 
combination caused by a lesion in the pons, which at the same 
time produces hemiplegia of the opposite side of the body. 
This combination is a natural one, in view of the close relations 
of the nuclei of the sixth and seventh nerves. Indeed, Lock- 
hart Clarke, Meynert, and others are of opinion that there is 
one nucleus which is common to both nerves — a view not 
shared in by Gowers and others. The manner in which the 
root of the facial nerve winds around the sixth-nerve nucleus 



THE ORBITAL MUSCLES. 553 

must also have an important bearing on the occurrence of 
associated paralyses of these nerves. (See also Lagophthal- 
mos, Chap, vii.) 

Hemiplegia due to a lesion of the cortical motor region, 
which might happen to be combined with paralysis of the 
sixth nerve as a distant symptom, offers no difficulty in its 
diagnosis from hemiplegia with sixth-nerve paralysis in pon- 
tile disease ; for, while the latter is a crossed paralysis, the 
former is homonymous. 

Paralysis of the jiftJi nerve with hemiplegia of the opposite 
side points to disease in the pons. Neuroparalytic ophthalmia 
is said to be the rule in basal lesions of the fifth nerve, and 
to occur very rarely in nuclear or fascicular lesions. 

The orbicular sign may be noticed in some attacks of 
apoplexy with hemiplegia after consciousness has returned. 
It consists in this, that the hemiplegic person, who during 
health has been able to close each eye separately, and who 
even now can close both eyes together, or the eye on the 
sound side alone, is unable to close the eye on the paralyzed 
side by itself. This sign usually passes away after a short 
time. Sometimes when both eyes are closed it requires a 
greater effort to bring the eyelids together on the paralyzed 
side. I saw the orbicular sign very well marked and persistent 
in an obscure case of Dr. Wallace Beatty's where a gross 
cerebral lesion was suspected. 

Extensive basal lesions, especially the syphilitic, may pro- 
duce symptoms due to involvement of widely separate struc- 
tures, without interfering with those which intervene ; hence 
they tend to implicate several nerves without reference to 
system or function. 

Convergent Concomitant Strabismus. — This is the con- 
dition which is popularly known as inward " cast " or *' squint." 
It makes its appearance in children, when they begin to take 



554 DISEASES OF THE EYE. 

an interest in small objects, such as toys and pictures ; or a 
little later, when the first lessons are learned — in short, when 
they begin to make frequent and prolonged demands on their 
internal recti and accommodation, most commonly from the 
age of three to six years. 

The term "concomitant" (concomitatus, accompanied) is 
given to it in contradistinction to "paralytic" strabismus; 
because in it the squinting eye, by virtue of the normal innerva- 
tion of the associated muscles, accompanies the straight one 
in all its movements to an equal extent. At the primary 
position of the eyeballs, in a case of concomitant squint, the 
parallelism of the visual axes is defective, and as the eyes are 
moved from side to side, the defective parallelism continues in 
the same degree, neither increasing nor decreasing. Moreov^er, 
if the straight eye be shaded by the surgeon's left hand, and 
the squinting eye by this means be obliged to fix the object 
of vision — ^.g-, the tip of the index finger of the surgeon's 
right hand held up two or more feet distant in the median line 
— it will be found that the straight eye is now squinting in- 
ward. This deviation of the straight eye is called the sec- 
ondary deviation, and in these cases of concomitant strabismus, 
it is equal in degree to the primary deviation of the squinting 
eye. Because the internal rectus of the good eye, being 
associated in its action with the external rectus of the squint- 
ing eye, when the latter muscle is forced, in the foregoing 
experiment, to roll its eye outward in order to bring it to fix- 
ation, the internal rectus of the good eye, receiving a similar 
nervous impulse, rolls that eye inward to the same extent as 
the squinting eye has been rolled outward ; and the good eye 
will therefore present, under the covering hand, an internal 
strabismus of the same amount as that w^iich had previously 
been present in the squinting eye. This is an important point, 
for it is an aid in the differential diagnosis of this form of 



THE ORBITAL MUSCLES. 555 

strabismus from the paralytic form, in which the secondary 
deviation is greater than the primary one (see general prin- 
ciple No. 2, p. 526). 

In order to decide which is the squinting eye, it is merely 
necessary to direct the patient to look at an object held up in 
the median line on a level with his eyes, and a few feet in front 
of him. 

In concomitant strabismus, of course, both eyes never squint 
simultaneously, as one hears it sometimes stated by parents. 

Causes. — Squint is never due, as is popularly supposed, to 
fright, imitation, or naughtiness ; nor is it ever brought on by 
the patient looking at a lock of hair, or other object, which 
may happen to hang very much to one side. 

Bonders * pointed out that in a large proportion of cases 
of convergent strabismus, the refraction is hypermetropic, and 
he drew the conclusion that hypermetropia is to be regarded 
as the cause of the strabismus in the following way : It has 
been shown (Chap, i, p. 23) that with each degree of normal 
convergence of the optic axes, a certain effort of accommoda- 
tion is associated. The greater the angle of normal converg- 
ence, the greater is the possible effort of accommodation. 

Of this physiologic fact. Bonders said, the hypermetrope 
often unconsciously takes advantage, and, in order to brace 
up his accommodation in an excessive degree for the sake of 
distinct vision with one eye, he increases the angle of con- 
vergence of the optic axes by rotating the other eye (Z, Fig. 
146) somewhat inward. The angle I' is thus made larger 
than the angle /, and the effort of accommodation normally 
belonging to the angle V is obtained for the eye R, which 
consequently receives a clearer image of the visual object A on 
its retina. But, inasmuch as all hypermetropes do not squint. 
Bonders considered that there were contributing circumstances 

■'^ " Accommodation and Refraction of the Eye," p. 292. 



556 DISEASES OF THE EYE. 

which caused each hypermetrope to unconsciously decide be- 
tween distinct monocular vision with strabismus and indistinct 
binocular vision. The latter, he said, is likely to be preferred 
if the condition of the refraction and the acuteness of vision is 
the same in each eye ; while, if the retinal images differ much, 
by reason of one eye being more ametropic than its fellow, 
from nebulous cornea, or from other causes, the desire for 
binocular vision would be less strong, and the imperfect eye 




Fig. 146. 

would deviate inward for the sake of the resulting increase of 
accommodation in the perfect eye. 

It is admitted on all hands that hypermetropia is one of 
the causes of internal strabismus, but, as Schweigger * has 
pointed out, it is not the only cause, and probably not even 
the principal cause, for the following reasons : i. If Bonders' 
theory be complete, convergent strabismus must always ap- 
pear, whenever there is binocular hypermetropia, along with 

■* " Ueber das Schielen," Berlin, i88i,and " Handbuch der Augenlieilkunde," 
fifth edition, p. 146. 



THE ORBITAL MUSCLES. 557 

the conditions which reduce the value of binocular vision. 
But strabismus is often absent while the degree of ametropia 
is markedly different in the two eyes, or while the acuteness 
of vision is very defective in one eye. 2. According to 
Bonders' theory, the higher the degree of the hypermetropia, 
the greater should be the tendency to strabismus ; and yet 
clinical observation shows that this is not the case. 3. In 
periodic strabismus the influence of hypermetropia and of 
the accommodative effort is very evident ; and yet these cases 
only go to show that, while hypermetropia is very frequently 
one of the causes of strabismus, it is not the only or 
most important one ; for here, clearly, some factor necessary 
for the production of a permanent squint is wanting. 4. 
Bonders' theory fails to explain the occurrence of convergent 
strabismus in emmetropic and in myopic individuals, where, 
of course, no excessive effort of accommodation is required. 

Schweigger considers that a want of equilibrium between 
the muscles is the chief cause of strabismus (divergent as 
well as convergent), and that convergent strabismus is mainly 
due to a preponderance in the power of the internal over the 
external recti ; or, with equal accuracy one might say, to an 
insufficiency of the external recti. It would seem that in 
hyermetropia the external recti are apt to be congenitally less 
powerful than the internal recti ; while in myopia congenital 
insufficiency of the internal recti is the more common condi- 
tion. The internal recti do, however, sometimes preponderate 
in emmetropia, and even in myopia ; and therefore convergent 
strabismus does sometimes occur in these forms of refrac- 
tion. Whatever be the condition of refraction, strabismus is 
more apt to be developed if the value of binocular vision be 
diminished by imperfect sight in one eye. Schweigger does 
not, however, give any proofs of this preponderance of certain 
muscles. 

Spontaneous cure of strabismus does sometimes take place, 



558 DISEASES OF THE EYE. 

most commonly between the tenth and sixteenth year of age. 
That it may happen with hypermetropia and with defective 
vision in one eye is strongly against Bonders' theory. 

According to Hansen Grut's view,* convergent squint origi- 
nates in, and is maintained as the result of, an innervation which 
induces in the interni a shortening greater in amount than 
that which is desirable. 

Single Vision in Concomitant Convergent Strabismics. — For 
the most part these patients do not complain of double vision ; 
although diplopia is the rule in cases of convergent strabismus 
due to paralysis of the external rectus. Why is this ? The 
image of the object looked at, it will correctly be said, must 
be formed in the squinting eye in each of these kinds of stra- 
bismus, on a part of the retina not identical with that in the 
fixing eye, but lying to the inside of it ; and hence the image 
of the object should be projected by the squinting eye to its 
own side of the true position of the object (homonymous 
diplopia), and the latter should therefore be seen doubled. It 
is seen doubled in the paralytic form ; why not also in the 
concomitant form ? The only explanation of this circumstance 
which, until within the last few years, had been put forward 
was, that convergent concomitant strabismus being a quasi- 
physiologic condition, the patient's mind involuntarily sup- 
presses the annoying image belonging to the squinting eye 
in a manner analogous to that by which, when we are deeply 
interested in conversation, all extraneous sounds are unper- 
ceived, although they, too, must reach the nerve of hearing. 
This suppression of the image belonging to the squinting eye 
was believed to be the more easy, owing to the indistinctness 
of the image itself, formed as it is on a peripheral part of the 
retina, while in the good eye it falls on the macula lutea. 
We often find, moreover, that the squinting eye is ad initio 



Bowman Lecture," i^ 



THE ORBITAL MUSCLES. 559 

more defective (macula cornea, higher degree of hyperme- 
tropia, astigmatism, etc.) than its fellow, and it was held that 
this, too, rendered suppression of its image more easy. Such 
a suppression of the image is possible, and it no doubt does 
occur in many cases of strabismus ; but it is certain, as pointed 
out by Schweigger, that it does not occur in all of them, perhaps 
not even in most of them. It would be beyond the scope 
of this handbook were I to go into the arguments on this 
point. Suffice it to say that, in those cases where suppression 
of the image of the squinting eye does not take place, a 
certain participation in the act of vision on the part of this 
eye, when not too blind, is implied. One of two events takes 
place in those cases : Either the region of the retina, on 
which, in the squinting eye, the image of the visual object is 
formed, becomes functionally developed into a stop to a great 
extent physiologically " identical " with the macula lutea of 
the straight eye, and then something approaching normal 
binocular fusion of the images comes about, and hence single 
vision ; or else diplopia is actually present, although, as a rule, 
it passes unnoticed by the patient, owing to its having become 
habitual to him. In some cases the first of these conditions 
is the actual state, in others it is the second which exists. I 
shall mention one fact in support of each, but must refrain 
from entering more deeply into the subject. In support of the 
first is the occurrence, not rarely observed, of crossed diplopia 
after operation for concomitant convergent strabismus, even 
when there is no divergence produced ; and in support of the 
second, the diplopia which intelligent patients often admit when 
they are carefully examined with the aid of a red glass before 
the good eye. 

Amblyopia of the Squinting Eye. — In a large proportion of 
the cases of internal concomitant strabismus, the squinting 
eye, even where there is no marked astigmatism, and where 
the media are clear, is amblyopic. Schweigger states the 



56o DISEASES OF THE EYE. 

proportion of these amblyopic cases to be 30 per cent., but I 
believe the percentage to be much larger. It has been a very 
generally accepted opinion that this amblyopia is due to want 
of use on the part of the squinting eye, in consequence of the 
suppression of the image on its retina, and hence it is termed 
amblyopia exanopsia. If this view were the correct one, we 
ought always to find only slight amblyopia of the squinting 
eye in children soon after strabismus comes on ; while it should 
be of high degree — in fact, the eye should be almost useless 
— in adults who have not been operated on, and in whom 
monolateral strabismus had been present since childhood. 
And yet marked amblyopia may often be found in children in 
the squinting eye, while in adults the squinting eye often has 
very good vision — in short, the amblyopia of the squinting eye 
is not progressive, as it would be were it exanopsia. Again, 
many squinting eyes, when the straight eye is covered, instead 
of fixing the visual object with the macula lutea, remain un- 
changed in position, or even turn inward more than before 
(amblyopia with excentric fixation) ; and in less well-marked 
cases of the same sort, although there is no excentric fixation, 
yet the preference for fixation with the macula lutea is lost, 
and uncertainty of fixation results, no one part of the retina 
being more useful for that purpose than another. It is held 
by many that this form is characteristic of amblyopia ex- 
anopsia, and is the result of the strabismus ; but it is identical 
with a form of congenital amblyopia often present in only one 
eye without strabismus (p. 512). A strong argument in favor 
of amblyopia exanopsia is the improvement which often seems 
to take place in the vision of the squinting eye by systematic 
separate use, or after the strabotomy. But it is tolerably cer- 
tain that where the improvement takes place the defective vis- 
ion has been due rather to retinal asthenopia than to amblyopia ; 
and if at the outset patients be pressed to discern the test- 
types, they often succeed in producing a better acuteness of 



THE ORBITAL MUSCLES. 561 

vision than they at first seemed to possess. In many cases 
separate use fails altogether in improving the vision of the 
squinting eye, even when it is not very defective — a fact which 
is unfavorable to the amblyopia exanopsia theory. The cir- 
cumstance that in alternating strabismus the sight of each eye 
is good, cannot be regarded as proof in favor of amblyopia 
exanopsia rather than against it. 

The explanation which Schweigger gives of the very fre- 
quent presence of amblyopia in the squinting eye, is that it is 
congenital ; and, far from being the result of the strabismus, is a 
factor in its production, just as opacities of the cornea, or high 
degrees of ametropia, have always been admitted to be. 

There are tliree clinical varieties of convergent concomitant 
strabisnitis . — (i) Periodic. (2) Permanent alternating. (3) 
Permanent monolateral. Periodic strabismus occurs only 
when some great effort of accommodation is required. It 
sometimes is the first stage of permanent monolateral or of 
alternating strabismus ; but these two latter forms do not 
always have their beginning in the periodic form, which often 
continues as periodic to the end of the chapter. In alternating 
strabismus, the patient squints sometimes with one eye and 
sometimes with the other. In permanent monolateral strabis- 
mus the squint is confined to one eye. 

Measurement of Convergent Strabismus. — The amount or 
degree of the deviation of the squinting eye from its normal 
position is not the same in every case, and the size of the 
squint is measured by one of the following methods. Which- 
ever of them be used, it is important that the patient be directed, 
during the test, to regard a distant object placed in the median 
line and on a level with his eyes. If he look at a near object 
the squint may be overestimated, by reason of its increase 
with accommodation. 

I . By the linear method w^e measure the number of milli- 
meters by which the eye deviates from its normal position. 
47 



562 



DISEASES OF THE EYE. 



The good eye is shaded, and the squinting eye is caused 
to fix an object in the median Hne — by preference a distant 
object. Close under the margin of the Hd a strabometer 
(Fig. 147) is then placed, so that the o point may coincide 
with a perpendicular let fall from the center of the cornea. 
The shade being removed from the good eye, the squinting 
eye is allowed to resume its abnormal 
position, and the degrees recorded on 
the instrument, under a perpendicular 
let fall from the center of the cornea in 
this position, are read off. They give 
the amount of the deviation. 

2. Hirschberg's method * consists in 
estimating the degree of deviation by 
the position of the corneal reflex of a 
candle-flame held straight in front of, 
and about a foot from, the eye. Where 
there is no squint this reflex is situated 
at or (with large angle y) slightly to the 
inner side of the center of the pupil in 
each eye. In a convergent squinting 
eye it is displaced outward, and Hirsch- 
berg recognizes five groups of strabis- 
mus. Group I (Fig. 148 representing 
the right eye), in which the reflex is 
nearer to the center than to the margin 
of the pupil. This represents a strabis- 
mus of less than ten degrees, and no operation is indicated. 
Group 2, in which the reflex is at or about the margin of the 
pupil, representing a strabismus of 12° to 15°, and indicating a 
simple tenotomy, with occasionally a tenotomy of the other in- 
ternal rectus. Group 3, in which the reflex is outside the pupil- 




FiG. 147. 



Cetitralblatt f. p. Aiigenheilhunde, 1 886, p. 5. 



THE ORBITAL MUSCLES. 563 

lary margin, about half-way between the center of the pupil and 
the corneal margin. This represents a strabismus of about 25°, 
and indicates a tenotomy of the internal rectus, combined with 
a moderate advancement of the external rectus. Occasionally, 
later on, a tenotomy of the other internal rectus will be re- 
quired. Group 4, in which the reflex is on or near the corneal 
margin ; representing a strabismus of 45° to 50^, and indicat- 
ing a tenotomy of the internal rectus, along with energetic 
advancement of the external rectus, and sometimes a later 
tenotomy of the other internal rectus. Group 5, in which the 
reflex is on the sclerotic, between the margin of the cornea 
and the equator bulbi. This represents a strabismus of 60° 




Fig. 148. 

to 80°, and requires the combined operation, with strongest 
possible advancement of the externus. Even this is some- 
times insufficient, and a tenotomy of the internal rectus, or 
even the combined operation on the other eye, may be subse- 
quently required. This is a modification of the linear method, 
and is a convenient one in routine practice. 

3. Priestley Smith measures strabismus by means of a 
double tape, used in conjunction with the ophthalmoscope, as 
shown in the figures 1 49, i 50, and 151. The patient places the 
ring P on one of his fingers and holds it to his cheek. The 
observer places the ring on the forefinger of the hand Avhich 
holds the ophthalmoscope ; this keeps his eye at a distance of 



564 



DISEASES OF THE EYE. 



one meter from the patient's face. He uses his disengaged 
hand as a fixation-object for the patient, holding it edgewise 
toward the patient, and letting the graduated tape slide be- 
tween his fingers. A small weight at the end of the tape 
keeps it stretched as the hand moves in either direction. 



F O- 



Fig. 149. 




Figure 1 50 illustrates the measurement of a convergent 
strabismus of the right eye. The patient, seated below the 
lamp and holding the tape as above described, is told to look 
at the mirror. The observer, holding the ring and the 
mirror in the ricrht hand, throw^s the light on the patient's left 



THE ORBITAL MUSCLES. 565 

eye (L) ; i. c, the fixing eye. He sees the corneal reflex in 
the center of the pupil, and knows thereby that this eye is 
fixing properly. He then throws the light on the right eye 
(i?), and sees the reflex situated eccentrically outward, and 
knows that this eye deviates inward. Taking the graduated 
tape between the fingers of his left hand, and telling the 
patient to watch this hand, he moves it outward along the tape 
(see Fig. 149), and meanwhile watches the corneal reflex in 
the deviating eye. When this latter reaches the middle of the 
pupil he reads the position of the hand upon the tape. The 
axis of the deviating eye (i?) has moved from R' to 0, through 
the angle R' R 0. The axis of the non-deviating eye (Z) has 
moved through an equal angle L L' . The angular move- 
ment of Z, as measured by the tape, equals the angular devia- 
tion oi R. 

Figure i 5 i illustrates the measurement of a divergent stra- 
bismus of the right eye. The hands must be reversed, but 
the principle is the same as before. 

The graduated tape is a substitute for a graduated arc of a 
circle, but does not exactly correspond with such an arc. The 
error involved is, however, so small as to be of no importance 
if the observer keep his two hands at about the same distance 
from the patient's face. In this mode of measuring a strabis- 
mus it is the excursion of the fixing eye which is actually 
measured, and the excursion of the deviating eye is supposed 
to be equal to it. If the excursions of the two eyes are un- 
equal, the result would be at fault. The method, though 
difficult to explain in words, is very quick and satisfactory in 
practice. 

4. The Angular Method. — The object aimed at here is to 
determine the size of the angle which the visual axis of the 
squinting eye makes, with the direction it should normally 
have. For this purpose a perimeter is employed. Let us 
suppose that the right eye (R, Fig, 152) be the squinting eye, 



566 



DISEASES OF THE EYE. 



and that P o P h& the arc of the perimeter. The patient is 
placed at the instrument, as though the field of vision of his 
squinting eye were about to be examined. He is directed to 
look at a distant object {A) with his good eye (Z). The visual 
line from R should now pass through the point o, but it passes 
through the point n, and therefore o R n is the angle of the 
strabismus. The surgeon finds the position of ;^ by carrying 




Fig. 152. 



the flame of a candle along the perimeter, until, with his eye 
placed behind the flame, he finds that the corneal image of the 
flame occupies the center of the pupil. The flame itself will 
then be at ;/, and the size of the squint-angle may be read off 
there. This gives us the optic axis of the eye ; but, to be 
strictly accurate, we must remember that the position of the 
visual axis is what we require, and that it lies a few degrees 



THE ORBITAL MUSCLES. 567 

further inward, according to the size of the angle y- The 
angular method is now in general use instead of the linear 
method, than which it is more accurate. 

5. A good subjective method for determining the dimension 
of a strabismus, but which can onh* be used where diplopia is 
present, is what ma\' be called the method by tangents. Upon 
a wall of the consulting-room, in a horizontal line, and so as to 
be on a level with the e\-es of the patient, who is placed about 
three meters from the wall, are permanently marked out 
tangents of angles of five degrees each, as seen from the place 
where the squinting e\'e is. Exactly opposite to the squindng 
eye is o^, while toward the right and left the points are marked 
up to 45° or more. The flame of a candle being held at 0°, 
and one eye of the patient being covered with a red glass, he 
is called on to indicate the position of the image belonging to 
the squinting eye, and the number on the wall which corre- 
sponds to this gives the angle of the strabismus. For the 
purpose of estimating parah'ses of the orbital muscles, a similar 
row of tangents, or se\-eral such, may be marked out in the 
vertical direction. 

Mobility of the Eye Oiiizcard in Convergent Concomitant 
Strabismus. — This is often defective in the squinting e\'e. and 
sometimes also in the fixing e}'e. The excursiveness of the 
lateral motions of the e\-eball may be measured by the peri- 
meter. Placing the patient as though the field of vision, say 
of his right eye, were about to be examined, the patient is 
directed to follow with his e\-e the flame of a candle carried 
along the perimeter from o^ toward 90^, in the temporal 
direction, and when it is found that the e\-e cannot be turned 
any further in this direction, the extreme position is noted by 
the position of the candle at the perimeter. The corneal 
image of the flame must, of course, be central when the posi- 
tion of the flame is read oft". In a similar way the mobiiit}- of 
the eve inward ma\- be measured. In the normal eve the 



568 DISEASES OF THE EYE. 

mobility in each direction is about 45°. In strabismus we 
simply compare the outward mobility of the squinting eye 
with that of the good eye, to ascertain how much, if anything, 
the former lacks of its normal amount. 

Treatment. — The bearing of hypermetropia on the produc- 
tion of many cases of strabismus, long since suggested the 
idea of curing the deviation by spectacles, which would correct 
any existing hypermetropia. The accommodation, having been 
paralyzed by atropin, is kept under its influence for some 
weeks or months, spectacles which completely correct the 
hypermetropia and astigmatism being meantime constantly 
worn. Should the patient require to use his eyes for near 
work while under treatment, it is necessary that he should have 
suitably higher + glasses for his near work. Occasionally 
good cures are effected by this means ; and when a periodic 
strabismus in a child comes under my care, I always think it 
worth while to attempt its correction in this way ; but in gen- 
eral it is, by itself, of no use whatever. 

Ortlioptic Treatment. — To Javal * is due the credit of devis- 
ing this method ; but although he did so some years ago, it 
is only recently that the treatment has been introduced into 
practical ophthalmology. 

In order that the treatment may be carried out, it is neces- 
sary, in the first instance, that the strabismic person should 
have diplopia. If the latter be not present spontaneously, it 
has to be developed ; and it is sometimes possible, when the 
sight in the squinting eye is not too defective, to give the pa- 
tient diplopia — i. e., to make him continuously conscious of 
the presence of the image belonging to the squinting eye. 
This may be done by means of exercises with a prism, base 
downward, before the deviated e}-e, and a candle-flame as 



* Annates d' Ocutis/ique, July and August, 1871. See also March, April, 
May, June, November, and December, for the same year. 



THE ORBITAL MUSCLES. 569 

visual object. The exercises are to be repeated daily until 
diplopia without a prism is established. Javal recommends 
the following exercise to develop diplopia : A screen — ^.g., a 
large sheet of cardboard- — is held vertically between the two 
eyes, while the patient is directed to look at a candle-flame 
about two meters in front of him. Double vision may imme- 
diately appear ; but, if it does not, it may be brought out by 
now and then covering the good eye for a moment, or by 
placing before it a red glass, which can soon be done without. 
Less brilliant visual objects are gradually substituted, until, 
finally, the double vision will continue even when, at first cau- 
tiously, the screen is removed. 

Double vision having been estabUshed, we proceed to enable 
the patient to fuse the double images — i. e., to obtain binocular 
vision — and when we have succeeded in doing this we have 
cured the squint. The end in view is best effected by means 
of a stereoscope, into which, in place of the usual prisms, 
-f 6 D lenses have been introduced. The focal distance of 
these lenses being about the length of an ordinary stereoscope, 
rays coming from the slides, and passing through them, fall 
into the observer's eye as parallel rays ; the accommodation 
consequently is suspended, and under normal conditions the 
visual lines are parallel, as though looking at a distant object. 
In the normal state the double picture or diagram will seem 
to be single, but to the strabismic patient, in whom diplopia is 
present, it will be double. Our duty, then, is to diminish the 
distance between the pictures, until the patient finds himself 
just able to fuse the images into a single impression. After a 
day or two the distance is increased slightly, and so on, until, 
finally, the normal position is reached. It is needless to say 
that in these exercises all errors of refraction must be elimi- 
nated by the proper glasses.* 



* The existence, or otherwise, of true binocular vision maybe ascertained by the 
48 



570 DISEASES OF THE EYE. 

The pictures used in the stereoscope should be geometric 
figures, or specially designed pictures, in order that both 
surgeon and patient may the more readily recognize their 
fusion. 

Only the very slight degrees of strabismus are adapted for 
the attempt at cure by orthoptic treatment. A marked devia- 
tion will not be amenable to it. Moreover, it makes demands 
both upon the patience and intelligence of the patient, which 
are rarely fulfilled, especially in hospital practice. A field 
more fertile in good results for this treatment is found in the 
completion of cures, which have been commenced by operative 
measures. 

Operative Treatment. — Division of the tendon of the internal 
rectus muscle, combined, sometimes, with advancement of the 
insertion of the external rectus, is the measure which has to 
be applied in most of the cases which come under our notice. 

simple experiment of giving the patient a book to read, and holding a cedar pencil 
half-way between his eyes and the page at right angles to the lines of type. If binoc- 
ular vision be present, the pencil will not offer any impediment to the reading ; 
but if it be not present, parts of the page will be hidden behind the pencil. The 
reader may prove this by performing the experiment on himself, first with both 
eyes open (binocular vision), and then with one eye shut. 

Another method is that known as Hering's drop experiment. A cylinder 
about 25 cm. long, and wide enough to take in both eyes of a person, is provided 
— at the opposite end from that placed around the eyes — with two strong wires 18 
inches long, which jut out in continuation, as it were, of the cylinder, but which 
are bent outward sufficiently to keep them out of view of the patient. Between 
the ends of these wires a fine thread is stretched, with a small bead fastened at 
its middle point, so that the bead may occupy the center of the field when the pa- 
tient looks through the cylinder. During the experiment the thread is in the 
horizontal position, and the bead is used as the patient's fixation-point. Small 
balls of different sizes (peas, beans, etc.) are then let fall from a height, one after 
another, a couple of dozen times or more, some of them in front of the thread, 
some of them behind it. If the patient have normal binocular vision, he will be 
able to say each time with certainty whether the ball falls in front of or behind 
the thread ; but if he have not true binocular vision, if only one eye be used, he 
will merely guess at the position of the falling ball, and will make frequent 
mistakes. 



THE ORBITAL MUSCLES. 571 

I am strongly opposed to operative interference in patients 
under fiv^e years of age, and very much prefer that they should 
be seven or eight years old, or even older. Early childhood 
offers a decided obstacle to the careful adjustment of the 
operation and to orthoptic treatment. 

In order that the operative proceeding may be adapted to 
each case, the following points must have been previously 
noted with care : a. The dimension of the strabismus angle. 
b. The lateral mobility of the eyes, especially the mobility 
outward of the squinting eye. c. The refraction of the eyes, 
and the acuteness of vision of the squinting eye, as well as the 
presence or otherwise of diplopia. The first, in order that 
glasses for the correction of any hypermetropia may be worn 
if desirable after the operation ; the second, because, ceteris 
paribus, an operation for convergent strabismus will produce a 
more marked effect if the vision in the squinting eye be good 
than if it be very defective ; and the third, because the presence 
of diplopia encourages the hope that binocular vision may be 
restored. 

Rules which will insure in every case, with absolute cer- 
tainty, the desired degree of operative effect cannot be laid 
down. The following will be found to answer in the majority 
of cases, and if the effect be now and then too great, it can 
easily be adjusted by bringing forward the internal rectus, or 
by setting back the external rectus, within a few days after the 
operation. In every instance it should be the desire of the 
surgeon to leave two or three degrees of strabismus behind ; 
for the effect of the operation is apt to increase within a year, 
and, if absolute parallelism be present at first, divergence may 
ultimately supervene. The establishment of binocular vision 
when possible would do away with this remnant of strabismus ; 
but under any circumstances the latter does not detract from 
the cosmetic result. 

If the vision of the squinting eye be fairly good, and the 



572 DISEASES OF THE EYE. 

deviation amount to not more than i 5° or 20°, and the power 
of the external rectus be sufficient, the correction can be 
effected by the tenotomy of the internal rectus of the squint- 
ing eye. A strabismus of 20° will require the free separation 
of the delicate connections between the anterior surface of the 
tendon, or capsule of Tenon, and the conjunctiva as far back 
as the caruncle, in order that the tendon may be free to con- 
tract. For a deviation of 15° or less this separation should 
not be so free, or should be quite omitted ; or, if a very slight 
effect be desired, it can be produced by drawing the conjunc- 
tival wound together, after an operation which has been con- 
fined strictly to the insertion of the tendon. 

If the vision of the squinting eye be fairly good, and the 
power of the external rectus sufficient, and if the squint be 
more than 20°, it is advisable to divide the proceeding between 
the eyes — e. g., if it be 30°, about 20° are corrected by tenot- 
omy of the internal rectus of the squinting eye, and the 
remainder by tenotomy of the internal rectus of the fixing 
eye. If desired, the effect of the tenotomy in one or both 
eyes may be increased by a suture passed through a fold of 
conjunctiva at the outer side of the globe, and tied tightly. 

If, although the vision of the squinting eye be good and 
the deviation not more than 20° or 25°, there be marked loss 
of power of the external rectus muscle, tenotomy of the inter- 
nal rectus alone will often lead to disappointment, and a good 
result will require this tenotomy to be combined with advance- 
ment of the external rectus, the operative measures being 
confined to the squinting eye. But advancements in such 
cases as this must be very cautiously carried out, as an exces- 
sive effect may easily be produced. The external rectus 
should be but slightly brought forward. 

If the deviation exceeds 35°, even when there is good vision 
in the squinting eye, and no loss of power in the external 
rectus, tenotomy of the internal rectus of each eye is rarely 



THE ORBITAL MUSCLES. 573 

sufficient, and as a rule advancement of the external rectus of 
the squinting eye must be combined with these measures. 

With a deviation of 30° to 35° and loss of power in the 
external rectus, the demand for advancement of the external 
rectus becomes more imperative. The correction of squints of 
40° and more are, in every instance, to be effected by tenot- 
omy with vigorous advancement in the squinting eye, and 
subsequent tenotomy of the internal rectus in the good eye. 

In cases where the vision of the squinting eye is much re- 
duced, the deviation great, and the insufficiency of the exter- 
nal rectus marked, the combined operation in one or 
both eyes is the proper proceeding. /^^^"^^^ 

Mode of Operating for Strabismus. — Tenotomy. 
— The instruments required for this operation are a 
spring-stop speculum, a small toothed forceps, blunt 
scissors, somewhat curved on the flat, and two strab- 
ismus hooks (Fig. 153). 

The eye having been thoroughly cocainized, the 
patient is placed on his back, the surgeon standing 
in front of him and on his left-hand side if the left 
eye is to be operated on, or behind him if it be the 
right eye. The speculum is then applied, and the fig. 153. 
conjunctiva over the insertion of the tendon of the 
internal rectus is seized with the forceps, and incised with 
the scissors between the forceps and the eye. Into the open- 
ing thus made the points of the closed scissors are inserted, 
and, with a snipping action, a passage is made through the 
subconjunctival tissue ; from the conjunctival aperture to the 
upper border of the tendon in case of the left eye, or to its 
lower border in the right eye. The scissors are now laid aside, 
but the conjunctiva is still held in the forceps ; and, with the 
right hand, the point of the hook is passed through the open- 
ing and along the passage, until the edge of the tendon is 
reached. The point of the hook being kept in contact with 



574 DISEASES OF THE EYE. 

the sclerotic, the instrument is then turned rapidly around and 
under the tendon, and is brought close up to the insertion of 
the latter into the sclerotic, care being taken that the whole 
breadth of the tendon lies on the hook. The forceps are now 
laid aside, and the hook carrying the tendon is transferred to 
the left hand. One blade of the scissors, held in the right 
hand, is now inserted between the globe and the tendon, and 
the latter is completely divided at its insertion. The second 
hook is then employed for searching, above and below, for 
any strands of the tendon which may be left undivided, the 
test for complete division being that the hook can be brought 
up without obstruction to the margin of the cornea. If the 
smallest segment of the tendon be left undivided, the result of 
the operation is apt to be unsatisfactory. Immediately after 
the operation a marked diminution in the mobility of the eye 
inward should be looked for ; as this motion can now only 
take place by aid of any remaining connective-tissue attach- 
ments of the muscle to the eyeball and capsule of Tenon. If 
this defect in motion be not present, or in only a slight degree 
in comparison with the supposed extent of operation, it may 
be concluded that the tendon is imperfectly divided, and a new 
search for undivided filaments must be made. To estimate 
this loss of motion it is necessary, before the operation, to note 
the degree of mobility of the eyeball inward, and to compare 
it with the inward motion of the other eye. 

The effect of the operation may be diminished, if found 
necessary, by drawing the edges of the conjunctival wound 
together with a suture, the tendon being thus prevented from 
uniting with the globe so far back. The more conjunctiva we 
include in the suture at each side of the wound, the more will 
the effect of the tenotomy be reduced. This restricting suture 
should be applied when the immediate result of the tenotomy 
is greater than expected or desired. 

As the edges of the conjunctival wound cannot be accu- 



THE ORBITAL MUSCLES. 575 

ratel}' adjusted with sutures, none are applied for that purpose. 
They are only used, as above, to diminish the operative effect ; 
or, when an extensive loosening of the subconjunctival tissue 
has been performed, to prevent sinking of the caruncle. 

The subconjunctival operation for strabismus, proposed by 
the late Mr. Critchett, is performed as follows : A fold of 
conjunctiva is seized close to the lower margin of the insertion 
of the muscle, and incised with blunt-pointed scissors, so as 
to expose the tendon. A strabismus hook is passed through 
the opening and under the tendon. The scissors are now in- 
serted and opened slightly, one point being kept close to the 
hook, while the other is passed between the tendon and the 
conjuncti\"a, and the tendon is divided close to its insertion. 
This method is very generally adopted by English surgeons. 
For myself I prefer the operation (von Graefe's) previously 
described, as it much more readily admits of modifications of 
the effect. 

In von Arlt's method, instead of a hook being passed under 
the tendon in the first instance, it is seized with the forceps 
with which, just previously, the conjunctiva had been raised. 
In other respects the proceeding is the same as von Graefe's, 
than which it is said to be less painful. 

The immediate and ultimate effects of a tenotomy are b}' no 
means identical. Immediately after the operation the effect is 
very marked, owing to the loosening of the tendon from its 
insertion. In a few da}'s, when it becomes reattached, the 
effect diminishes, and in the course of some weeks there is 
again an increase in the effect, and this increase continues for 
about a year, as above stated. 

The ultimate result may, with tolerable certainty, be esti- 
mated immediately after the operation by testing the power 
of convergence. If the patient be directed to look with both 
eyes at the surgeon's finger held in the middle line, and it be 
approached to within 12 or 15 cm. of his nose, and if the con- 



576 .DISEASES OF THE EYE. 

vergence of the eyes can be maintained at that distance, the 
effect will not be too great. But if at a distance of from 1 8 to 
20 cm. the operated eye ceases to converge, or begins to di- 
verge, or if even at 1 2 cm. the convergence, although accom- 
plished, cannot be maintained for more than a few moments, 
and that then the operated eye deviates outward, ultimate 
divergence may be expected, even though the actual position 
of the visual axes be correct. A restricting suture must be 
applied in such cases. 

Sometimes, although the patient converges up to 12 cm. 
satisfactorily, and maintains the convergence at that distance 
for some moments, the eye will then rotate inward. In such 
cases there is apt to be a recurrence of the strabismus. 

Advancement. — In cases of convergent squint, in which it is 
desirable to combine advancement of the external rectus with 
tenotomy of the internal rectus, the latter is done first, as 
above described, at the same sitting. 

An opening is then made in the conjunctiva immediately 
over the insertion of the external rectus, and as long as the 
breadth of the tendon. The band of conjunctiva between the 
opening and the cornea is separated up with the scissors from 
the sclerotic, for to it the tendon has to be fastened later on. 
A strabismus hook is now passed under the tendon, and 
brought well up to its insertion, care being taken that the 
whole width of the tendon is held on the hook. A needle 
carrying a fine silk suture is introduced from its upper margin 
between the tendon and sclerotic, and passed through the 
tendon at its middle line. In the same way another suture is 
passed behind the tendon from its lower margin, and through 
it, close to the first suture. Each of these sutures is knotted 
firmly on the tendon, a long end being left to each (Fig. 154). 
The tendon is separated off with the scissors from the sclerotic 
close to its insertion. The sutures are passed through the 
conjunctival flap in the direction of the muscle, and are respec- 



THE ORBITAL MUSCLES. 



577 



tivel}- tied with their own ends. A greater or less effect is 
produced, according as the sutures are placed further or nearer 
to the insertion of the tendon, and according as they are drawn 
more or less tightly. I have found this method perfectly 
satisfactory. 

Immediately after the combined operation is finished there 
should be no divergence, nor should there be marked loss of 
motion of the eyeball inward. In either case the effect is too 




Fig. 154. 



great, and must at once be diminished by an adjustment of the 
advancing sutures, or a bringing forward of the internal rectus. 
In my opinion, even if it lie in the plan of the treatment to 
supplement the tenotomy, or combined operation, on the 
squinting e}'e. by a tenotomy, or combined operation, on the 
fixing eye, both eyes should not be operated on at one and 
the same sitting. An interval of a fortnight or more should 
elapse, in order that the true effect of the first proceeding 
may be accurately gaged, and then the surgeon will be in a 
position to know how to regulate his operative measures for 
the other eve. 



578 DISEASES OF THE EYE. 

After a strabismus operation a light bandage is applied, and 
is changed morning and evening for forty-eight hours, when, 
if no suture has been used, it may be discarded. If sutures 
have been employed, the bandage is retained until they come 
away. 

Dangers of the Strabismus Operation. — I have never seen 
any inflammatory reaction after a strabismus operation, not 
even after an advancement, nor have I ever seen any serious 
accident during the operation. Puncture of the sclerotic with 
the scissors while the tendon was being divided has occurred 
in the hands of some operators, but I confess I cannot under- 
stand how such an accident could happen, unless the operator 
had his own eyes shut. It is also stated that eyes have been 
lost after squint operations through orbital cellulitis, which, 
beyond doubt, must have been brought on by the introduction 
of septic matter upon the instruments. 

Occasionally a small arterial branch may be divided during 
the operation, and this, bleeding into the capsule of Tenon, 
may cause rather alarming exophthalmos. The protrusion 
goes back in a few days with use of a pressure bandage. I 
have only seen the occurrence twice. 

Sinking of the caruncle, some months after the tenotomy, 
when it does rarely occur, can be remedied in the following 
way : The conjunctiva is divided vertically about six mm. from 
the caruncle. The inner lip of the wound is raised, scissors 
curved on the flat passed in, and the subconjunctival tissue as 
far as under the sunken caruncle separated. The subconjuncti- 
val tissue under the outer lip of the wound, and as far as the 
corneal margin, is loosened in the same way, and the two flaps 
are brought together with a suture, which includes a sufficiency 
of conjunctiva to draw the caruncle well forward. 

Treatment Subsequent to Operation. — It is generally necessary 
for the patient to wear the correcting spectacles for his h}'per- 
metropia either constantly or for near vision only, according 



THE ORBITAL MUSCLES. 579 

as the result of the operative measures makes it more or less 
desirable to suspend the accommodation. After some months 
it is usually possible to leave off the spectacles, except for near 
vision. 

A cure of the strabismus, in the sense of removal of the 
deformity, can be attained by operation in every case, and 
by itself affords ample reason for undertaking the operation. 
But a cure, in the true sense of the term, involves restoration 
of binocular vision,"^ and this is very rarely obtained by opera- 
tive measures alone. 

Orthoptic exercises with the stereoscope (p. 568) are of 
great value in completing a cure which has been almost 
effected by operation. The deviation, which has been re- 
duced to a minimum by the operation, may sometimes be 
quite eliminated, and, still more important, binocular vision 
may sometimes be developed. Where the attending circum- 
stances of the case, both clinical (acuteness of vision, diplopia) 
and personal (patience and intelligence of the patient), admit 
of it, an effort should always be made to effect such a cure. 

Insufficiency of Convergence, or Insufficiency of the 
Internal Recti Muscles, and Divergent Concomitant 
Strabismus. — In the normal condition the orbital muscles are 
in a state of equilibrium, no one muscle or pair of muscles 
having more power over the e\-eballs than its fellow. 

Insufficiency of the internal recti muscles, or insufficiency 
of convergence, as it is more correctly called, implies a dis- 
turbance of this equilibrium. The converging power of the 
internal recti, in these cases, is so much weakened that they 
are obliged to make a constant effort to prevent the eyes, or 
one of them, from becoming divergent, and it is only the de- 

* The importance of binocular vision consists in the fact that it is chiefly by its 
aid we estimate distances finely and observe the shape of objects. Even plane 
surfaces are seen much more accurately with binocular than with monocular 
vision. 



58o - DISEASES OF THE EYE. 

mand for binocular vision which stimulates the muscles to this 
effort. 

Muscular asthenopia is the symptom caused by this insuffi- 
ciency. The patients complain that after reading, writing, 
sewing, or employment at other near work for a time, they 
begin to find the objects spreading, becoming indistinct, and 
perhaps doubled. Pain in and about the eyes comes on. 
These symptoms gradually increase, until the work has to be 
discontinued. 

A great deal has been written within recent years upon the 
relationship of some nervous diseases, especially epilepsy, to 
want of power in one or more of the orbital muscles. It has 
been thought that " eye strain," from want of coordination in 
these muscles, sometimes aggravated, if it did not actually 
cause, epilepsy ; but the outcome of the whole discussion 
seems to be that there is no such connection. 

The diagnosis of insufficiency of convergence can be made 
by the following methods : 

(<^) The patient is directed to look at the tip of the surgeon's 
finger held up in the middle line. The finger is brought slowly 
closer to the eyes until a certain point is reached where the in- 
ternal rectus of one eye ceases to act, the other eye still re- 
maining in fixation. The first eye, upon the finger being ad- 
vanced a little more, usually becomes divergent. 

(/?) If the tip of the finger be held some 20 cm. from the 
patient's eyes, and if, with his other hand, the surgeon cover one 
of the eyes, say the right, while the left is caused to fix the finger- 
tip, it will be found that the eye under the hand is diverging, 
and, when the hand is removed from it, it makes an inward 
motion, in order again to fix the finger-tip. The explanation 
of this is that when one eye is covered there is nothing to be 
gained in the way of single vision by an excessive exertion of 
the weak internal recti ; and consequently the eye which is 
excluded from the act of vision is abandoned to the control 



THE ORBITAL MUSCLES. 



581 



of the external rectus, and only returns to its normal position 
when, being restored to participation in the act of vision, 
diplopia would otherwise be present. 

(c) The following is von Graefe's test for insuf- 
ficiency of the internal recti : A dot with a fine line 
drawn vertically through it (Fig. 155) on a sheet of 
white paper is given to the patient to look at, at his 
usual reading distance. Before one eye, say the right, 
a prism of about 10° with its base downward is held 
vertically. This, in the normal condition, w^ould pro- 
duce a double image of the dot, so that the figure 
would seem to be a line with two dots, the upper dot 
being the image belonging to the right eye. In in- fig. 155. 
sufficiency of the interni the image of the right eye 
would not only be higher than that of the left, but it would 
also stand to the left (crossed double images) more 
or less, so that here the picture is that of two lines, 
each with a dot, the upper line and dot standing to 
the left-hand side (Fig. i 56). This crossed diplopia 
indicates divergence. The explanation of the ex- 
periment is as follows : When a prism is held be- 
fore the right eye the possibility of binocular vision 
is removed, and, insufficiency existing, the weak 
internal rectus of the right eye has no object in 
greatly exerting itself, and consequently abandons 
the eye to the traction of the external rectus. 
Hence the divergence and the projection of the 
image of this eye to the opposite side. 

The degree of insufficiency existing may be 
determined by this same experiment. If a weak 
prism be held with its base inward before the left 
eye, in the above case, the images of the lines will appear to be 
brought closer. By gradually increasing the power of the 
prism, one will be found which brings the Hues together, so that 



Fig. 156. 



582 



DISEASES OF THE EYE. 




the picture will now be that of two dots over each other on 
one line. This prism is the measure of the insufficiency. 

{d) Landolt estimates the amount of insufficiency of con- 
vergence by means of the meter angle and amplitude of con- 
vergence. For an account of the method I must refer the 
reader to his valuable work.* 

((f) Maddox's rod test is an admirable method for ascer- 
taining the condition of the muscular equilibrium of the eye- 
balls and for estimating any existing derangement of it. 

The apparent lengthening of a flame into a line of light, 
when looked at through a strong cylinder, is utilized to make 

the two images so dissimilar that 
no desire to unite them remains. 
The chief advantage of this prin- 
ciple is that slight malpositions do 
not, as with prisms, vitiate the result 
materially.- A glass rod mounted 
in a circular metal disc, as in figure 
I 57, may be used ; or a piano-cylin- 
der with a radius of about 20 mm. ; 
or a piece of corrugated glass ; or 
a flat series of thin glass rods side 
by side. The best flame to employ is that of a gas-jet 
turned low, at a distance of five mm. or six mm., and the 
appearance is improved by a piece of blue glass before the 
other eye, to equalize the illumination of the two images. 
The line of light is at right angles to the axis of the cylinder. 
If it pass through the flame, the balance is perfect ; if not, the 
defect is measured by the deviating angle of the prism which 
is found to bring them together, or, preferably, by a litho- 
graphed scale, placed with its zero just behind the flame, so 
that the figure crossed by the line of light gives the deviation 



Fig. 157. 



*"The Refraction and Accommodation of the Eye," 1886, p. 501. 



THE ORBITAL MUSCLES. 583 

ill degrees. For vertical diplopia the scale should be vertical, 
and for horizontal diplopia horizontal. In either case the axis 
of the cylinder should be parallel to the scale. When the 
cylinder is vertical, it should be shaded from the light of the 
window. By placing the patient's head in different positions 
the diplopia can be measured in all parts of the motor field. 
Vertical and horizontal scales should, for this purpose, be 
fixed on the wall, with their zeroes coinciding at the position 
of the flame. For near-vision tests a flame is too large. A 
scale should be used on a black background, with a small 
silvered hemisphere or bead fixed to its zero, to be a source of 
reflected light from the window or from a flame. 

This test is also very serviceable in overcoming the sup- 
pression of the false image in old squints, and for discovering 
the latent paresis of an ocular muscle. 

Insufficiency of the internal recti is a common attendant 
upon myopia. It is also found with emmetropia, and even 
with hypermetropia. 

Concomitant divergent strabismus is a further development 
of the same condition. 

Treatmejit. — In moderate degrees of myopia, the use of 
such concave glasses as will permit the patient to read at 35 
cm. distance may relieve the asthenopic symptoms. 

Decentration of these glasses may give further aid. If the 
glasses be so set in the spectacle-frame that their centers are 
on the outer side of the visual lines, the inner half of the 
glasses act as prisms with their bases inward, and by them the 
rays are broken inward — /. e., toward the macula lutea in each 
eye, so that a slight divergence may take place without diplo- 
pia, etc. In this way the internal recti are relieved. Should 
the case be one demanding the use of convex glasses (hyper- 
metropia, presbyopia) the decentration must be inward. 

A more perfect and accurate method is that of prescribing 
prisms, bases inward, to be worn for reading and other near 



584 DISEASES OF THE EYE. 

work. These may be combined with concave or convex glasses, 
where such are indicated. The prism, which is the measure 
of the insufficiency (see above), is divided between the two 
eyes. If it be four degrees, a prism of two degrees is placed, 
base inward, before each eye for near work. Very high prisms 
cannot be ordered, owing to the color effects they produce ; 
and in cases where they would be required, the insufficiency 
can be only partially corrected. 

Operative Treatment. — This consists in weakening the too 
strong external rectus by tenotomy. The danger of the 
method is that convergent strabismus with homonymous diplo- 
pia for distant objects may result, unless the case be suitable 
for operation. Only those cases are suitable in which absolute 
divergent strabismus is present ; or those in which, with a 
prism of not less than ten degrees, base inward, before one 
eye, the flame of a candle at three meters distance is seen single, 
or if it be perhaps doubled for a moment, then becoming again 
single. When with such a prism single vision is present, the 
external rectus by an effort must have overcome the effect of 
the prism, and it is admissible to deprive the muscle of the 
power represented by that effort or prism. If diplopia be pro- 
duced by a prism of ten degrees the tenotomy is contraindi- 
cated, for the effect of the latter could not be modified to the 
slight power of abduction indicated by a weaker prism. A 
source of error in the ascertaining of this abduction prism 
which must be guarded against is that the patient may sup- 
press the image of one eye, and that his single vision may be 
merely due to the fact that he is seeing with the other alone. 
The higher the abduction prism, the more extensive may be 
the division of the subconjunctival tissue, etc., while with 
weak abduction the effect must be diminished by a conjunc- 
tival suture. 

Immediately after the operation there should be a certain 
amount of convergence, as shown by homonymous diplopia 



THE ORBITAL MUSCLES. 585 

in the middle line for the flame of a candle at three meters dis- 
tance. This convergence, or diplopia, should not be greater than 
can be corrected by a prism often degrees. Moreover, if the 
candle be moved from the middle line i 5° to the opposite side 
from the operated muscle (to the right if the left external rec- 
tus has been tenotomized), there should be no convergence 
(no diplopia), and a vertical prism before one eye should only 
cause double images placed directly over each other. If by 
these experim.ents it be shown that the operation has produced 
an excessive effect, the latter must be diminished by a suture 
drawing the lips of the conjunctival wound together, and in- 
cluding more or less conjunctiva, according to the excess to 
be corrected. Or if a suture has already been applied, and 
the result be still in excess, it must be withdrawn, and a still 
more restricting suture inserted. In all these cases converg- 
ence must necessarily be present when the candle is carried 
over to the side of the operated muscle ; but this disappears 
— except perhaps at the very most extreme position on that 
side — as also the convergence in the middle line, by reason 
of cicatricial contraction at the new^ insertion of the tendon ; 
always provided that the indications for the operation and its 
performance, as above set forth, have been accurately at- 
tended to. 

Nystagmus. 

This term indicates an involuntary oscillation of the eyeballs 
from side to side — the most common form — in the vertical 
direction, or rotary (caused by the oblique muscles). 

It is most commonly found with congenitally defective vi- 
sion — microphthalmus, coloboma of the choroid, in albinos, 
etc. — but it may be acquired, and is often seen in those em- 
ployed in coal mines. It occurs in about one-half the cases 
of disseminated sclerosis.* 



* According to Gowers ("Diseases of the Nervous System," Vol. i, second 
49 



586 DISEASES OF THE EYE. 

In the congenital cases, it is probable that the absence of the 
stimulus which accurate retinal impressions afford interferes 
with the functional development of the coordinating centers 
for the orbital muscles. In coal mines, the very defective light 
and the blackness of the surroundings deprive the miners of 
any defined retinal impression, and hence their coordinating 
centers are apt to become deranged. But as it is chiefly those 
who work in one constrained position on their sides, with eyes 
directed obliquely upward, who become affected, it seems 
likely * that this unnatural and long-continued direction of the 
eyeballs is an important factor in the production of the affec- 
tion ; indeed, it is probably to a great extent a professional 
cramp, like writer's cramp. In fact, a case of acquired nystag- 
mus in a compositor, due to working in a strained position, 
has been recorded. f 

Those patients in whom nystagmus is due to a congenital 
defect of vision do not complain of oscillation of the objects 
they look at ; but individuals who become affected with it in 
later life are much troubled with that symptom, especially at 
the onset. 

Treatment. — In congenital cases, which admit of improve- 
ment of vision, a cure, partial or complete, is sometimes brought 
about when the vision improves. If strabismus be present it 
should be cured, after which a diminution in the oscillations 
may result. In miner's nystagmus, the all-important measure 
is a permanent relinquishment of mine work ; and this is fre- 
quently followed by satisfactory results. 



edition), nystagmus occurs often in ataxic paraplegia, primary spastic paraplegia, 
and hereditary ataxia, sometimes in severe multiple neuritis and syringomyelia, but 
rarely in progressive muscular atrophy. 

* Vide S. Snell, Brit. Med. Jonrn., July II, 1 89 1. 

fSnell, Trajis. Ophthal. Soc. , Vol. xi, p. 102. 



CHAPTER XIX. 

DISEASES OF THE ORBIT. 

Orbital Cellulitis, or Inflammation of the Connective 
Tissue of the Orbit. — Tlic symptoms of this affection are : 
Erysipelatous swelling of the lids, especially of the upper lid ; 
serious chemosis ; pain in the orbit, increased on pressure of 
the eyeball backward ; violent facial neuralgia ; exophthalmos, 
with impairment of the motions of the eye in every direction ; 
and high fever. 

Vision is not generally affected, but sometimes it is so from 
optic neuritis, and then, too, mydriasis is seen. The cornea is 
often completely or partially anesthetic. 

The surgeon, by pressing the tip of his fourth finger be- 
tween the eyeball and the margin of the orbit, may feel a more 
or less resistant tumor. This gradually increases in some 
one direction, the integument in that position becomes redder, 
fluctuation becomes pronounced, and the abscess finally opens 
through the skin, or into the conjunctival sac, the pointing 
being usually at the upper and inner angle of the orbit. Res- 
toration to the normal state, as a rule, comes about ; but in 
some cases complete atrophy of the optic nerve supervenes. 

Causes. — I. Idiopathic; f.^.,cold. 2. Traumatic (perforat- 
ing injuries, foreign bodies). 3. Extension of inflammation 
from surrounding parts (erysipelas, diseased tooth, ethmoidal 
cells). 4. ^Metastasis (pyemia, metria). 5. Sequelae of fevers 
(scarlatina, typhoid, purulent meningitis, influenza). 

Treatment. — Locally, poultices or warm fomentations ; and, 
when pus has formed, its earliest possible evacuation — b}' 

587 



588 DISEASES OF THE EYE. 

preference from the conjunctival sac. The general constitu- 
tional treatment suitable to each case need not be discussed 
here. 

Thrombosis of the cavernous sinus gives rise to symptoms 
which may be mistaken for those of an orbital process. The 
affection is described at page 550. 

Periostitis of the Orbit. — Acute periostitis has many 
symptoms in common with phlegmonous inflammation of the 
orbital connective tissue which generally accompanies it ; but 
may usually be distinguished from the latter inflammation 
occurring independently by the fact, as first pointed out by the 
late Mr. John Hamilton, of Dubhn,* that in it pressure on the 
orbital margin is painful. The absence of this tenderness, 
however, is not always conclusive of the absence of periostitis, 
especially when the latter is restricted to the deep parts of the 
orbit. In periostitis the eyelids are not usually so swollen as 
in inflammation of the orbital tissues. Suppuration may take 
place, necrosis in consequence of detachment of the periosteum 
may come on, and communications with the neighboring 
cavities be formed. 

In secondary syphilis, or in later stages of the disease, a 
syphilitic gumma of the orbital wall may form. This is ac- 
companied by violent frontal neuralgia or headache, increasing 
at night. Proptosis f {j:p6, forivard ; -rmaiq, falling) occurs, 
with marked loss of motion in the eyeball in one or more 
directions. This loss of motion is a very characteristic symp- 
tom, and serves to assist in the diagnosis between this affection 
and other orbital tumors. It is probably due to an extension 
of the inflammation to the connective tissue of the orbit and to 
the muscles themselves. 

Again, periostitis of a chronic form, and without tendency 

* Dublin Journal of Medical Sciences, 1836. 
I Protrusion of the eyeball. 



THE ORBIT. 589 

to suppuration, occurs most commonly in persons with a con- 
stitutional rheumatic tendency. It is accompanied by pain in 
and about the orbit, and there is increased tenderness on 
pressure of the eyeball backward. Exophthalmos and all 
other outward signs are here usually wanting. 

The prognosis depends much on the seat of the inflammation. 
If this be in the deep parts of the orbit, thickening of the 
periosteum may cause permanent protrusion of the eyeball ; 
extension of the inflammation to the optic nerve may result in 
optic atrophy ; the orbital muscles, or the nerves which supply 
them, may be implicated, with consequent paralysis ; or, 
finally, the inflammation of the periosteum may strike into the 
meninges of the brain. When the inflammation is near the 
margin of the orbit, early evacuation of pus, if it has formed, 
reduces the process within safe bounds ; and this position is 
one of less danger, in respect of its surroundings, than if the 
process be deep in the orbit. 

Causes. — Periostitis of the orbit may be caused by blows 
or other traumata, b}' extension from neighboring cavities, by 
syphilis, or rheumatism. 

Treatment. — Warm fomentations. Exit given to pus, if 
possible. Constitutional measures. 

Caries of the orbit is very frequently the result of perios- 
titis, but often commences in the bone, and in either case is 
usually due to tubercular disease. It is also seen in very late 
syphilis. A trauma is sometimes the immediate cause of its 
onset. 

It may attack any part of the orbital walls, its favorite seats 
being the margin above and to the outside, or below and to 
the outside. When it is seated deeply in the orbit it often 
causes exophthalmos and pain. At the margin of the orbit it 
produces edema and swelling of the eyelids, with conjuncti- 
vitis ; suppuration comes on, and the abscess finally opens 
through the integument or conjunctiva. A fistula is apt to 



590 DISEASES OF THE EYE. 

remain for a length of time, and, the skin being drawn into 
this, ectropion of the hd is produced. If a portion of dead 
bone comes away, the resulting cicatrix is liable to maintain 
the ectropion (p. 254). 

Treatment. — The evacuation of purulent collections at the 
earliest possible moment — if deep in the orbit, by the careful 
introduction of a long bistoury — the insertion of a drainage- 
tube, and the regular washing out of the cavity with anti- 
septic solutions, until no more rough or bare bone can be felt 
with the probe. 

Injuries of the Orbit. — Wounds of the soft parts in the 
supraorbital region, involving the supraorbital nerve, are be- 
lieved by some to be capable of producing a reflex amau- 
rosis (p. 512), and many such cases have been recorded under 
the name of supraorbital amaurosis. By the light of modern 
physiology and ophthalmology it is not probable, I might 
say not possible, that any such reflex could take place, and it 
seems likely that the blindness in those recorded cases was 
brought about in some other way ; e. g.^ orbital periostitis, 
concomitant injury to the eyeball itself, facial erysipelas, in- 
tracranial lesions, and so on. 

Perforating injuries of the orbit through the eyelids by 
prods of walking-canes, etc., and the lodgment of foreign 
bodies in the orbit are serious accidents. They are liable to 
be followed by phlegmonous inflammation ; or, if a pointed 
weapon (stick, sword-cane, etc.) has been pushed into the 
orbit with some force, it may pass through the bony wall and 
perforate the brain, with fatal result. 

It is remarkable what large foreign bodies may be concealed 
in the orbit. I once saw a case in which a bit of wood, ^ 
of an inch long by i^ of an inch wide, lay unsuspected in the 
orbit for many weeks, without causing any marked displace- 
ment of the eyeball. 

Treatment. — Foreign bodies should be removed by dilata- 



i 



THE ORBIT. 591 

tion of their wounds of entrance, or by the formation of a 
new passage through the conjunctival fornix, and great care 
should be taken to prevent the onset of inflammation, or to 
keep it within safe bounds. 

Orbital Tumors. — In the diagnosis of an orbital tumor 
three questions present themselves : i. Is a tumor of the 
orbit present ? 2. Is the new growth confined to the orbit, 
or does it extend to neighboring cavities? 3. Of what kind 
is the new growth ? The diagnosis as regards any of these 
points does not often occasion much difficulty in advanced 
stages of the disease, especially where the growth occupies 
the anterior part of the orbit or protrudes from it. It is 
rather in the early and middle stages that difficulties in diag- 
nosis are apt to present themselves, and attention will here be 
mainly directed to those stages. 

Exophthalmos. — Of the signs by which the presence of a 
tumor is diagnosed in its early stages, by far the most impor- 
tant, because the most constant, is exophthalmos. In the 
earliest stages of a growth which commences in the deepest 
part of the orbit, there may be, it is true, no exophthalmos, 
while other symptoms — defects of sight, pain, loss of motion — 
may already be present ; but when the grow^th attains to cer- 
tain dimensions, or if in the anterior part of the orbit there be 
even a small tumor, the eyeball must be pushed out of its 
place. 

An important diagnostic point in connection with the ex- 
ophthalmos caused by a tumor, is that its direction is almost 
always oblique and not straight forward, for orbital tumors 
commonly tend to develop more along some one wall of the 
orbit than along the others, and hence the eyeball becomes 
pushed toward the opposite side as well as forward. In 
cellulitis, edema of the orbital tissues. Graves' disease, and 
paralytic proptosis, the exophthalmos has a direction straight 
forward. Tumors growing from the apex of the orbit may. 



592 DISEASES OF THE EYE. 

in their early stages, cause no obliquity of direction in the dis- 
placement of the globe, and some tumors do not do so even 
in an advanced stage of their growth ; but these cases are ex- 
ceptional. Tumors, too, situated altogether within the mus- 
cular cone, of which the most common are tumors of the 
optic nerve, need not cause any lateral displacement of the 
globe. Again, the exophthalmos caused by an orbital tumor 
usually increases in degree slowly and gradually, differing in 
this respect from exophthalmos due to most of the other 
causes, in which either a sudden or a rapid development of the 
exorbitism is the rule. While tumors are sometimes present 
in both orbits, especially lymphoma, or lymphosarcoma, yet 
it is infinitely more common for one orbit alone to be diseased ; 
and hence monolateral exophthalmos is suggestive of orbital 
tumor. 

Palpation in the orbit often provides a valuable sign, pro- 
vided that the new growth has come within reach in the ante- 
rior part of the cavity. In many cases, indeed, there is no 
difficulty whatever in recognizing the presence of an orbital 
tumor by this means, the sensation obtainable by the tip of 
the surgeon's finger pressed into the orbit being very definite ; 
but in other cases the evidence is not so clear, and a reasonable 
doubt may exist as to whether there is any abnormal resist- 
ance met with. By palpation we may gain some knowledge 
of the position, extent, shape, and consistence of the tumor, 
and whether it be adherent either to the walls of the orbit or 
to the eyeball. It is important, when practicable, to compare 
the result of examination of the diseased orbit with the con- 
dition of the sound orbit, and this can be done to greater 
advantage if palpation of the orbits be performed simulta- 
neously with a finger of each hand. 

Derangements of vision are often, but by no means always, 
present in the early and middle stages of the growth of an 
orbital tumor. Their occurrence depends frequently on the 



THE ORBIT. 593 

rapidity of the growth of the tumor rather than upon its size. 
In an early stage of a rapidly-increasing tumor, the sudden 
stretching of, and pressure on, the optic nerve may produce 
absolute blindness ; while in another case, with an equal 
degree of exorbitism, but which has been brought on by a 
slowly-growing tumor, vision may be unaffected by reason of 
the optic nerve becoming gradually accustomed to the change. 
Yet slowly-growing tumors w^hich spring from the optic nerve 
or its neighborhood or from the deepest part of the orbit, 
are competent, by direct pressure on, or by implication of the 
optic nerve, to cause serious loss of sight, even in an early 
stage, and with but little exophthalmos. Optic neuritis, and 
later on optic atrophy, are occasionally discovered with the 
ophthalmoscope. Diplopia is often present w^hen the globe is 
at first displaced, but disappears when the exophthalmos be- 
comes extreme or the vision defective. 

Pain is a symptom sometimes, but by no means always, 
present in cases of orbital tumors. It is especially liable to 
be complained of when the growth is increasing rapidly in 
size, even though it may not have attained to great dimen- 
sions. The pain is then often of a neuralgic kind, and very 
severe, from the unaccustomed pressure on branches of the 
fifth nerve in the orbit. Certain sorts of tumors are more 
liable to be attended by pain than others, and the nature of 
the pain, too, is to some extent characteristic of the sort of 
new growth. 

Loss of po-LL'cr of motion of the eyeball is a ver}^ common 
symptom in cases of orbital tumors. It is caused in some 
cases by the mechanical obstruction offered by the tumor, as 
a result of which motion of the eyeball becomes defective 
toward the side of the orbit on which the new growth is situ- 
ated. In other cases, the loss of motion is caused by stretch- 
ing of the muscles from the exophthalmos, or by implication 
of them in the new growth, or by atrophy of their tissue, or 
50 



594 DISEASES OF THE EYE. 

by paralysis of the orbital nerves from pressure. When there 
is little or no loss of motion, while the exorbitism is marked, 
the conclusion may be drawn that the tumor lies within the 
muscular cone. In every case the history, the rapidity of 
growth, the age and general condition of the patient are im- 
portant items for consideration. 

Implication of Neigliboriiig Cavities. — As regards the ques- 
tion whether the tumor is confined to the orbit or involves 
one or more of the neighboring cavities, it may be assumed 
that it is confined to the orbit, unless there are symptoms or 
signs which point in the opposite direction ; and in each case 
these symptoms and signs ought to be looked for. Tumors 
may either originate in one of these spaces and grow into the 
orbit, which is the more common event ; or, originating in the 
orbit, they may at a later stage spread to a neighboring space ; 
and it is often the history or progress of the case alone that 
can inform us which of these events has taken place. 

Tin nor s wliicli originate in the frontal sinus are usually either 
mucocele or exostosis. Mucocele of the frontal sinus fre- 
quently extends to the ethmoid sinus and thence first en- 
croaches on the orbit, pushing the eyeball downward and 
outward. Sometimes there is supraorbital pain, and some- 
times, when the nasal meatus has become involved, there is 
discharge from the nostril. The diagnosis in these cases is 
often obscure. Osteoma of the frontal sinus shows itself as 
a slowly-growing and densely-hard tumor almost free from 
pain, situated along the superior margin of the orbit, extend- 
ing into the latter and pushing the eyeball downward and 
forward. It may subsequently extend to the orbital plate of 
the ethmoid. An error in diagnosis is, I think, liable to be 
made sometimes when a tumor of the frontal sinus drives 
the outer table downward and forward, and when the latter 
gives to the touch the sensation of a bony growth. If the 
tumor also involves the ethmoid c Us, the lacrimal bone is apt 



THE ORBIT. 595 

to be similar!}' driven forward, and the liability to the error I 
have mentioned is further increased. Bon}- growths originat- 
ingr in the orbit ma\' invade the frontal sinus, and, whether 
originating there or in the sinus, are liable to produce absorp- 
tion of the tables of the skull without an}' cerebral symptoms 
to indicate the occurrence. 

Timiors of the ethmoid cells which encroach upon the orbit 
are likewise most commonh' either mucocele or osteoma. 
}yIucocele of the ethmoid cells presents itself in the orbit as a 
tumor gradual!}' increasing in size on the inner wall of tlie 
orbit, and pushing the eyeball outward and forward. W'lien 
it has grown sufficiently large, palpation of it will discover 
fluctuation. Tlie source of error just now referred to, when 
the lacrimal bone is pushed in front of a slowly-growing 
tumor of the ethmoid cells, must be borne in mind. The 
sharp posterior edge of the lacrimal bone is easih' felt for and 
found, and will direct the diagnosis into the right channel. 
Mucocele of the ethmoid cells encroaching on the orbit must 
also be distinguished from a dermoid cyst, but to this I shall 
return later on. Osteoma of the ethmoid appears in the 
orbit as a hard round swelling at the inner canthus, followed 
by a swelling of the cheek and displacement of the e}'e out- 
ward and forward. It is apt also to extend into the nasal 
meatus, driving the septum out of place, and to push the hard 
palate downward, so that examinations of the nose and of the 
mouth should be made in aid of the diagnosis. Enchondro- 
mata and fibromata also sometimes spring from the ethmoid, 
and extend into the orbit, and malignant growths ma}' be met 
with here. 

Tumors that spring from tlie body of tJie sp/ieiioid bone, or 
from the antrinn of tlie sphenoid, and encroach upon the orbit 
are rare, and the diagnosis of their origin in an earh' stage is 
practically impossible. Here, again, the examination of the 
nasophar}'nx is important. It is stated (Stedman Bull) that an 



596 DISEASES OF THE EYE. 

orbital tumor which soon causes bhndness, commencing in the 
temporal side of the field, and leaving the fixation-point un- 
affected to the last, while at the same time a growth appears 
in the nasopharynx, is likely to be one having its origin in the 
sphenoid antrum. Bony tumors — osteoma, hyperostosis, and 
exostosis — polypi, and sarcomata are the growths most fre- 
quently found to originate in the sphenoid antrum. 

Tinnors of the maxillary antnnn sometimes erode the floor 
of the orbit, and grow into that cavity, driving the eyeball 
upward and inward or upward and outward. The breadth of 
the cheek is increased, the nose becomes pushed toward the 
opposite side, and the roof of the mouth is pushed downward. 
Tumors of the antrum of Highmore sometimes cause pain in 
the teeth or in the region of the distribution of the intraorbital 
nerve, and there may be a dull pain in the region of the 
antrum. In some cases there is a discharge of pus or of blood 
from the nostril. 

Intracranial tninors do not often invade the orbit, and then 
it is tumors of the middle fossa which gain access through the 
sphenoid fissure and optic foramen. The diagnosis of the 
origin of the disease can only be made if cerebral symptoms 
have existed prior to any sign of a new growth in the orbit. 
Tumors of the pituitary body may encroach upon the orbit by 
way of the sphenoid fissure, and are apt to be associated with 
polyuria and bitemporal hemianopia, which serv^e to aid the 
diagnosis. A more common event, although not in an early 
stage of the growth, is the extension of a primary orbital 
tumor to the brain, either along the optic nerve, through the 
sphenoid fissure, or through the roof of the orbit by erosion 
of the bone. This occurrence is usually evidenced by the 
presence of cerebral symptoms ; but cases have been met with 
where no such symptoms existed, although the orbital growth 
had encroached upon the anterior or middle fossa of the skull. 

Diagnosis of the Nature of an Orbital Tumor. — As regards 



THE ORBIT. 597 

the nature of the growth which ma}' be present, it must be 
admitted that in many instances in the early stages of a deeply 
seated tumor, we have to rest content with an indefinite or pro- 
visional diagnosis, unless an exploratory operation, witlr punc- 
ture or harpooning of the mass, is practicable ; and such a 
procedure is often called for, in order to decide not only the 
nature of the tumor, but also its extent and origin. 

Orbital Cysts. — Dermoid c}'sts are those most frequently 
found, and they are usually congenital. Indeed, if an orbital 
tumor be congenital, it is, as a rule, either a dermoid cyst or 
an encephalocele. Dermoid c}-sts, although usually congeni- 
tal, do not often grow to an}- size until the age of pubert}- or 
later, and ma}* then for the first time give rise to troublesome 
s}'mptoms. The}' grow slowly, and finalh- reach ver}- consid- 
erable size, and then bulge out between the e}"eball and margin 
of the orbit. Pressure upon this protruding part causes it to 
diminish, while the exophthalmos is at the same time increased, 
and distinct fluctuation in the protruding part can be felt. 
The growth of the c}-st is unaccompanied b}- pain or other 
inconvenience. The contents are generally either serous or 
hone}'-like, and occasionalh' hairs and other epidermic forma- 
tions have been found in them. 

H}-datid c}-sts also occur in the orbit, and se\-eral of these 
cases have been observed in England. 

Treatment. — The c}'st should be freeh* opened at the most 
prominent point, evacuated b}- gentle pressure backward of 
the e}-eball, and the sac syringed out two or three times daih' 
with an antiseptic solution, until all discharge has ceased. 
The opening will then close, while the eyeball will alread}' 
have returned to its place. If the contents of the C}-st are 
solid, or nearly so. it becomes necessar}- to extirpate it /;/ toto. 
To do this, as in other tumors also, a horizontal incision 
must be made along the orbital margin through the e}'elid, 
in order that the cavitA" of the orbit mav be reached, or two 



598 DISEASES OF THE EYE. 

perpendicular incisions at either canthus through the upper 
lid may be made, and the latter turned upward. With hooks 
or forceps, and scalpel or scissors, the cyst wall must then be 
carefully separated from all adhesions. 

Exostoses occur as the result of inflammation of the bone 
and of periostitis, and also without any apparent cause, and 
are usually of the kind known as ivory exostoses. They 
spring most commonly from the ethmoid or from the frontal 
bone. 

All the bony tumors present, of course, the sensation of 
dense hardness to the touch ; but there are some mahgnant 
growths of such hardness that it may not be easy to tell them 
from the osteomata by palpation, and an exploratory puncture 
becomes necessary in order to decide the point. The growth 
of an orbital osteoma is excessively slow, in many instances 
commencing in infancy, and lasting into advanced life. In 
addition to the dense hardness of these tumors, the deciding 
points in the diagnosis are their usually globular and some- 
what nodulated surface, and their immobihty and direct con- 
nection with the walls of the orbit, ascertainable by touch. 

Operative interference in cases of exostosis of the orbit is 
only justifiable when the tumor does not grow from the roof 
of the orbit, as it then often involves the cranial cavity, and 
when there is reason to think it is attached to the orbital wall 
by a narrow base or pedicle. Several instances are on record 
in which the growth has become spontaneously separated by 
necrosis of its pedicle. Beyond destruction of the eyeball 
there is no danger associated with these tumors, even if their 
growth takes an intracranial direction ; but they cause serious 
disfigurement and much pain. 

Carcinoma and Sarcoma. — The first of these tumors takes 
its oricrin in some neig^hborimr cavitv, or from within the eve- 
ball, and grows into the orbit ; it never originates in the orbit. 
Sarcoma may originate in many different positions, most fre- 



THE ORBIT. 599 

quently, perhaps, in the periosteum and in the connective tissue 
about the lacrimal gland. These malignant tumors, after de- 
struction of the eyeball by pressure, or by phthisis following 
ulceration of the cornea, attack the bony walls of the orbit 
and its surroundings. 

The early extirpation of the tumor, with complete eviscera- 
tion of the orbital contents, affords, in general, the only pros- 
pect, and that a slight one, of saving the patient's life. 

Many forms of sarcoma, however, are non-malignant, espe- 
cially those which lie free in the orbit and arise from the con- 
nective tissue. Indeed, Panas * is of opinion that many cases 
of sarcoma, as also of lymphadenoma of the orbit, are due to 
infectious principles, toxins, or microbes, and are amenable to 
medical treatment by mercury, iodin, arsenic, or toxitherapy. 
So much certainly must be admitted — namely, that cases now 
and then present themselves, with all the signs and symptoms 
of orbital tumor, which ultimately undergo a purely sponta- 
neous cure, or one unexpectedly brought about by iodid of 
potassium. 

Pulsating ExopJitliabnos. — This title covers a great variety 
of vascular tumors, the majority of them having their origin 
within the cranium, while the remainder are truly orbital. 
Symptoms common to all these are : Proptosis ; the presence 
of peculiar bruits, which can be heard, over the orbit, and usu- 
ally also over a more or less extensive portion of the skull ;' 
and pulsation, apparent in the eyeball, or at some point of the 
orbital aperture. The last symptom may occasionally be ab- 
sent during the whole, or part, of the progress of the case. 
The intracranial vascular tumors with which we are most likely 
to meet are : Aneurysm of the ophthalmic artery at its point of 
origin from the internal carotid ; aneurysm of the latter vessel ; 
and, most commonly, arteriovenous aneurysm from communi- 

"^ Bi'it. Med. Jotirnal, October 19, 1895. 



6oo DISEASES OF THE EYE. 

cation of the internal carotid with the cavernous sinus — this 
latter of traumatic origin. In the orbit the following occur : 
True aneurysm of any of the arterial branches ; diffused or 
circumscribed traumatic aneurysm ; arteriovenous aneurysm of 
traumatic origin ; aneurysm per anastomosis ; and telangi- 
ectatic tumors. 

Hemorrhage is liable to prove fatal in these cases. 

Treatment. — Ligature of the common carotid affords the 
best prospect of cure. Digital compression of the same ves- 
sel has produced cure in some cases. Spontaneous cure has 
been observed occasionally in cases of arteriovenous aneurysm. 

Tumors of the Lacrimal Gland. — Slowly-increasing ex- 
ophthalmos, the eyeball being gradually pushed forward and 
inward, and its motions curtailed in the upward and outward 
direction, is a constant symptom here. In the region of the 
gland the upper eyelid seems to be swollen ; but palpation 
shows this to be caused by a growth situated behind the lid, 
and not in it, and, further, that the tumor originates in the 
orbit. The upper fornix of the conjunctiva is found, on ever- 
sion of the upper lid, to be pushed downward. After a time 
the blood-vessels of the upper lid become congested and 
tortuous, and when the tumor has grown very large the eye- 
lids cannot be closed, the eyeball becomes infected, and the 
cornea dry and opaque. 

Adenoma, or adenosarcoma, and fibroadenoma are the most 
common forms of tumor of the lacrimal gland. 

Extirpation of the growth at as early a stage as possible is 
indicated. The tumor is reached, either through an incision 
made through the lid parallel to the outer half of the upper 
orbital margin ; or, the external commissure having been 
divided, and the upper lid turned up, the gro\\th can be re- 
moved through an incision made in the conjunctiv^al fornix. 

Tumors of the Optic Nerve. (See p. 470.) 

Hernia cerebri, either in the form of meningocele or of 



THE ORBIT. 6oi 

encepbalocele, may invade the orbit. Its most common situa- 
tion is the upper and inner angle of the orbit, to which it gains 
access through the suture between the frontal and ethmoid 
bones. It appears as a fluctuating, often transparent, pulsat- 
ing congenital tumor. Pressure causes it to disappear, but 
gives rise, at the same time, to symptoms of cerebral irritation 
or pressure. 

A congenital tumor in the upper inner angle of the orbit 
must always be regarded with suspicion, lest it be a cerebral 
hernia, even though it does, not pulsate, or on pressure causes 
cerebral symptoms. In the large cerebral hernia death in the 
first few days of life is, we know, the rule. 

Exophthalmic Goiter (Graves' Disease, Basedow's Dis- 
ease). 

Symptoms. — The three cardinal symptoms of this disease 
are : Increased rapidity of the heart's action, which ma}^ 
reach 200 beats per minute ; tumefaction of the thyroid 
gland ; and exophthalmos. Of these the cardiac symptom is 
the most constant, and usually the first to appear ; either or 
both of the others ma}' be wanting. There is often also 
great emaciation, with outbursts of sweating and diarrhea. 
A venous murmur ma}- be heard in the neck ; and in females 
there is very commonly irregularity or suppression of men- 
struation. 

The disease has been observed at all ages, but is most com- 
mon in early adult Hfe. 

Von Graefe's sign is a very earh^, tolerably constant, and 
almost pathognomonic one ; it consists in an impairment of 
the consensual movement of the upper lid in association with 
the eyeball. When, in the normal condition, the globe is 
rolled downward, the upper eyelid falls, and thus its margin is 
kept throughout in a constant relation to the upper margin of 
the cornea. In Graves' disease the descent of the upper lid 



6o2 DISEASES OF THE EYE. 

does not take place, or only in an imperfect manner ; and, 
consequently, when the patient looks down, a zone of sclerotic 
becomes visible between the margin of the lid and the cornea. 
This symptom is often present prior to any exophthalmos, and 
hence its great diagnostic value. It may also continue after 
the latter disappears, although it is perhaps more common for 
it to disappear before the proptosis, and it is not seen, or but 
very rarely so, in protrusion of the globe from other causes. 
But the sign is not so absolutely pathognomonic as it was 
held by von Graefe to be. It may be absent in Graves' dis- 
ease, although very rarely so, in the early stages, and it is 
sometimes present in other diseased states, and even in health. 

Stellwag's sign is also very constant. It is incompleteness 
and diminished frequency of the act of involuntary nictitation. 

This act occurs sometimes only once in a minute ; or sev- 
eral rapid nictitations take place, and then a lengthened pause. 
The nictitation each time is incomplete, the margins of the lid 
not being brought together. The result of this may be that 
the lower third of the cornea becomes covered with pannus 
vessels, owing to the constant exposure ; for even during sleep 
the eyelids remain partially open. 

Dalrymple's sign consists in an abnormal widening of the 
palpebral aperture, due to retraction of the upper eyelid. It 
is this gaping of the eyelids which gives the characteristic 
staring aspect to the patient. This sign is often erroneousl}- 
attributed to Stellwag, or is included in his sign. The error 
is due to the fact that in the same paper * in which Stellwag 
first drew attention to what is above described as his sign, he 
discussed this other previously observed sign. According to 



* Wiener Med. Jahrblicher, xvii, p. 25, 1869. See also Klin. Monatsbl. fiir 
Aiigenheilkunde, 1869, p. 216, and " Graefe und Saemisch's Handbuch," vi, 
PP- 955, 956- 



THE ORBIT. 603 

White Cooper,* it was Dalrymple who first pointed out the 
latter, t 

Probably each of these "signs " is due to the one cause 
suggested by Sharkey f — namely, loss of power in the orbic- 
ularis rather than overaction of the levator. 

Otto Becker states that in a majority of the cases spon- 
taneous pulsation may be seen in the retinal arteries, but I 
have only found it sometimes. The vision — unless when cor- 
neal complications supervene — and condition of the pupil are 
unaffected by the disease. In some cases there is an increased 
flow of tears, but most of the patients complain of a dryness 
of the eyeballs. The sensibility of the cornea is diminished. 
Ulcers of the cornea are not common, but are said (von Graefe) 
to be more frequent in men than in women, although Graves' 
disease is more common in women. The exposure of the eye 
and dryness of the cornea are the chief causes of ulceration, 
when it occurs ; but Sattler inclines to the belief that it is also 
largely due to paralysis of the nervous supply of the cornea. 

The patients are often hysteric ; and even marked psy- 
chic disturbances have been noted, such as a peculiar and 
unnatural gaiety, rapidity of speech, and great irritability ; or, 
on the other hand, extreme depression, and even attempts at 
suicide have been observed. Also loss of memory and in- 
ability to make a mental effort. The motions of the eyeball 
have in some cases been defective — a fact for which the exoph- 
thalmos does not account. Trousseau's cerebral macula is 
often well marked. 



* The Lancet, May 26, 1849, P» 553- 

f Other conditions which produce widening of the palpebral aperture, or ' ' star- 
ing eye," are : I. Orbital tumor (mechanically). 2. Stimulation of the cervi- 
cal sympathetic. 3. Cocain (in slight degree, probably by reason of 2. — Jessop). 
4. Women after childbirth (hysteria). 5. In tetanus (spasm of occipitofrontalis). 
6. In complete amaurosis. 

I Trans. Ophth. Soc, Vol. xi, p. 204. 



6o4 DISEASES OF THE EYE. 

TJic progress of the disease is, as a rule, very chronic, ex- 
tending over months or years, but liable to fluctuations in the 
intensity of its symptoms. A few cases have been recorded 
in which it became fully developed in the course of some 
hours or days. After a lengthened period and many fluctua- 
tions the symptoms usually slowly disappear. Occasionally a 
slight permanent swelling of the thyroid may remain, and very 
often more or less exophthalmos. About 12 per cent, of the 
cases go from bad to worse, and end fatally from general ex- 
haustion, organic disease of the heart which may have come 
on, cerebral apoplexy, hemorrhage from the bowels, or gan- 
grene of the extremities. 

Causes. — Anemia and chlorosis are general conditions very 
often present, as are, also, irregularities of menstruation ; but 
it is probable that the latter should be regarded rather as a 
concomitant symptom than as a cause. Severe illnesses are 
recorded as having gone before the onset in many cases, and 
also excessive bodily or mental efforts. Great sexual excite- 
ment has been known to be followed by Graves' disease, and 
depressing psychic causes are not infrequent forerunners of 
it. In many instances, however, the patients have been per- 
fectly healthy, and no cause could be assigned. 

The enlargevient of tJie thyroid is due in the first instance to 
dilatation of its vessels ; but in a late stage hypertroph}^ of 
the gland tissue may be produced, and increase of its connec- 
tive tissue, and even cystic degeneration. Tlie exophthalmos 
is due to hyperemia of the retrobulbar orbital tissues, as is 
demonstrated by a vascular bruit often present, and the fact 
that steady pressure on the globe diminishes the protrusion. 
Hypertrophy of the orbital fat may be found postmortem, but 
is, doubtless, secondary to the hyperemia. 

The tlieory until of late widely held as to the nature of the 
disease, represents it as a lesion of the cervical sympathetic, 
which causes paralysis of the vasomotor nerves, and conse- 



THE ORBIT. 605 

quent goiter, exophthalmos, and pulsation and dilatation of the 
carotids and retinal arteries ; while it causes excited cardiac 
action, by reason of a permanent irritation of the excitomotor 
nerves of the heart, which also run in the cervical sympathetic. 
Here the difficulty arises that two of the chief symptoms are 
supposed to be explained as the result of paralysis, while the 
third is said to be due to excitation. The absence, as a rule, 
of a pupillary symptom is a strong argument against a lesion 
of the sympathetic. That a state of continuous irritation of the 
sympathetic should exist is improbable, and is without proved 
physiologic analogy. With regard to paralysis of the sym- 
pathetic causing the goiter and exophthalmos, it is doubtful 
whether it could do so ; for experimental division of the 
sympathetic has not produced these symptoms in animals, nor 
have they resulted in clinical cases of paralysis of that nerve 
in man, although the pupillary symptoms have been marked. 
Postmortem examination has no doubt in a very few instances 
revealed alterations in the cervical sympathetic ; but they 
were of an inconstant nature, and were wholly wanting in the 
vast majority of cases which have been microscopically ex- 
amined. 

These considerations tend to discredit the sympathetic 
theory. 

Professor Sattler, of Leipzig,* has advanced a theory which 
is worthy of consideration. He assumes a lesion of those 
circumscribed portions of the vasomotor center in the brain 
which preside over the vasomotor nerves of the thyroid gland 
and of the intraorbital tissue ; and believes that the great 
constancy with which enlargement of the thyroid and ex- 
ophthalmos are present indicates an intimate local relation of 
these two portions. He attributes the cardiac symptoms to a 
lesion of the cardioinhibitory center for the pneumogastric. 

*"■ Graefe und Saemisch's Handbuch," Vol. vi, p. 984, etseg. 



6o6 DISEASES OF THE EYE. 

He also regards Graefe's symptom as due to a central lesion ; 
one, namely, of the coordinating center for the associated 
motions of the lids and eyeball ; while Stellwag's symptom, 
he believes, as does Stellwag himself, to be due to a lesion of 
the reflex centers, which are excited by stimuli from the retina 
and from the sensitive nerves of the cornea and conjunctiva. 
Sattler's theory derives important support from the experi- 
ments of Filehne.* When this observer divided the restiform 
bodies in their upper quarter, although the incision was not 
carried so deep as to wound the roots of the vagus, yet the 
functions of the latter nerve became impaired, exophthalmos 
was produced, and, although the thyroid did not swell, there 
was vasomotor paralysis in the ears, thyroid, and anterior 
part of the neck. Hence Filehne concludes that Graves' 
disease may be produced by paralysis of certain nerve regions 
controlled by the medulla oblongata, and that the points 
traversed in common by the nerve-paths concerned are the 
restiform bodies ; that the exophthalmos and goiter depend on 
dilatation of the blood-vessels ; and that the increased heart's 
action is due to diminution or aboHtion of tone in the pneu- 
mogastric. Postmortem examinations in the human subject 
are necessary to establish Filehne' s theory ; but he points out 
that negative results from some of these would not be fatal to 
his theory, as the occurrence of functional affections of the 
central nervous system is admitted. Dr. William A. Fitz- 
gerald t has pointed out that exophthalmic goiter is frequently 
complicated by symptoms which are clearly due to a central 
lesion, such as symmetric paralysis of the external recti, paral- 
ysis of the associated motions of the eyes, and glycosuria. 



^"Zur Pathogenese der Basedow 'schen Krankheit," Sitziingsber. d. Phys. 
Med. Soc. zu Erlangen, July 14, 1879, P- 177- See also " Graefe und Saemisch's 
Handbuch," Vol. vi, p. looi. 

f '* Theory of a Central Lesion in Exophthalmic Goiter," Dublin Journ. Med. 
Soc, March and April, 1883. 



THE ORBIT. 607 

Hale White has recorded * a case of Graves' disease in 
which, after death, the only lesions were small hemorrhages in 
the floor of the fourth ventricle. 

A very able explanation of the marked preference shown 
by the symptoms for the right side of the body is given by 
Dr. W. A. Fitzgerald (loc. cit.) Bilateral symmetry (double 
exophthalmos, and swelling of each half of the thyroid), 
although not uncommon, is not always present, especially in 
the early stages ; and when want of symmetry exists, the pre- 
ponderance of the symptoms is on the right side — the right 
eye protruded, and the right lobe of the thyroid enlarged. It 
has occurred to him that the extreme constancy of the cardiac 
symptoms affords a clue to the problem of this preference, for 
he believes that it, too, is a right-sided symptom ; as it is 
more than probable that it is the right vagus which is chiefly 
concerned in the inhibition of the heart, and that the left has but 
little power of the kind. Arloing and Tripier's experiments, f 
and those of Masoin % and of Meyer, § show this ; and several 
cases are on record in which irritation of the right pneumo- 
gastric in man caused marked cardiac inhibition. Fitzgerald 
thinks, also, that the mode of development of the heart affords 
an explanation of the supply of that organ by the right rather 
than by the left vagus ; for soon after its appearance in the 
embryo it projects to the right side, where it comes in relation- 
ship with the corresponding vagus. 

The theory has recently been advanced that Graves' dis- 
ease is due to a toxemic secretion of the thyroid gland, on 
the grounds that cures have been obtained by excision of the 
gland, and that belladonna, which checks its secretion, also 
exerts a beneficial effect on the course of the disease. 

* Brit Med. Joiirn., March 30, 1889. 

f Archives de Physiologie, Vol. v, p. 166, 1873. 

X Bull, de r Acad. Boy. de Med. de Belg., Vol. vi, third series, p. 4. 

I " Das Hemmungsnervensystem des Herzens," p. 61, 1869. 



6o8 DISEASES OF THE EYE. 

Treatment. — A principal part of this consists in the care- 
ful regulation of the patient's general health and functions. 
Freedom from mental anxiety and excitement, regular hours, 
moderate exercise, and change of air are the most important 
items. 

The fluctuations which occur in the intensity of the symp- 
toms render it difficult to arrive at definite conclusions with 
regard to the efficacy of remedies, a vast number of which 
have been tried and lauded from time to time. In mild forms 
of the affection, and especially if the anemia be well marked, 
iron internally is beneficial, but in severe cases it has the 
opposite effect. Quinin in moderate doses has been employed 
with benefit in some cases. Trousseau recommended digitalis 
in large doses, but its effect must be watched. The beneficial 
action of iodid of potassium in ordinary goiter has suggested 
its use in this disease ; but under its influence the symptoms 
are sometimes aggravated, and it is doubtful whether they 
are ever relieved by it. Mr. Hulke * speaks highly of aconite, 
and Dr. Samuel Wilks f has no doubt as to the value of 
belladonna. Ergotin internally has been tried, and with ad- 
vantage in some instances. Sattler warmly recommends a 
well-regulated hydropathic treatment, when the patient is not 
too excitable. Paroxysms of cardiac palpitations, etc., are best 
combated with ice applied to the head, heart, and goiter. The 
sympathetic theory has induced the trial of a galvanic treat- 
ment of the cervical sympathetic. 

Dr. Gauthier J recommends antipyrin before everything else. 
Extract of the thymus gland has been occasionally employed 
and with encouraging results. 

Extirpation of the thyroid has been performed in recent 
years with success in some cases. 

* Trans. Ophthal. Soc, Vol. vi, p. 34. 

t 3 id.. Vol. vi,p. 56. 

X Ren. de Med., 1890, p. 409. 



THE ORBIT. 609 

The great number of remedies which have been proposed 
for it, demonstrate the incurable nature of most cases of this 
disease. 

In cases where the exophthalmos is so great that the cornea 
is exposed, even during sleep, it is desirable to perform tar- 
sorrhaphy (p. 231) ; and the same operation is indicated when, 
the disease having subsided, the exophthalmos still remains to 
a degree which gives the patient a disagreeable expression. 

Enophthalmos, or sinking of the eye back into the orbit, 
occurs to a certain extent in extreme emaciation, in Asiatic 
cholera, in paralysis of the sympathetic, and in facial hemiat- 
rophy, but it has been observed to an extreme degree as a 
result of injury. Thirteen cases of traumatic enophthalmos 
are on record. Beer * attributes it to atrophy of the retro- 
bulbar cellular tissue ; Lang f explains it by fracture or de- 
pression of a portion of the orbital wall, while Schap ringer X 
refers the condition to paralysis of Miiller's muscle from injury 
of the sympathetic nerve. 

*A?r/n'ves 0/ 0/>/i/ /i a/. {^Knapp and Schweigger), Vol. xxii, No I, p. 98. 

f Trans. OphtJial. Soc, Vol. ix, p. 41. 

%Klin. Monatsbl. f. Aiigenheilk., September, 1893. 



APPENDIX I. 

HOLMGREN'S METHOD FOR TESTING THE COLOR-SENSE. 

For the purposes of this method, a selection of Berlin worsteds is made, includ- 
ing red, orange, yellow, yellow-green, pure green, blue-green, blue, violet, purple, 
pink, brown, gray; several shades of each color being present, and at least five 
gradations of each tint, from the deepest to the lightest. Green and gray, several 
kinds each of pink, blue, and violet, and the pale gray shades, of brown, yellow, 
red, and pink must be well represented. But no two samples are to be of pre- 
cisely the same shade of the same color. This large number of colors and shades 
is used l)ecause the color-blind person escapes detection with more difficulty, and 
the diagnosis, therefore, is all the more certainly made, the greater the variety of 
colors. The normal-eyed individual readily selects the right ones from the mass, 
whilst the colorblind person, although the right ones are directly before him, 
picks out wrong ones, thereby disclosing the character of his defect. 

The test-color with which Holmgren invariably begins his examination is a 
pale, pure green, because green is the whitest of the spectral colors, and, conse- 
quently, the one in which the presence of color is most difficult to recognize — the 
one, in short, most easily mistaken for gray (= no color). Furthermore, as we 
all experience the most difficulty in deciding whether there be any " color " at all 
present in the very deepest shades (nearly black), and in the very palest shades 
(nearly white), it was plainly either a very dark or a very pale shade of green 
that should be employed ; and Holmgren's experience made him decide for the 
pale shade, as providing the most delicate test. 

As a test for the diagnosis of the particular kind of color-blindness, Holmgren 
recommends a purple (deep pink) sample ; that is, the whole group of colors in 
which red (orange) and blue (violet) are combined in nearly equal proportions, or 
at least in such proportions that no one of them sufficiently preponderates over 
the others, to the normal sense, so as to give its name to the combination. Purple 
is of especial importance in the examination of the color-blind, for the reason that 
it forms a combination of two fundamental colors (red and blue) — the two extreme 
colors — which are never confounded with each other. 

The method of examination and of diagnosis is as follows : The worsteds are 
placed in a pile on a table in broad daylight. The test skein (pale, pure green) is 
taken from the pile, and laid at a short distance from it, so as not to be con- 
founded with the other skeins during the trial ; and the person examined is then 
requested to select other skeins most resembling this in color, and to place them by 

6io 



APPENDIX. 6ii 

the side of the sample. It is necessary he should have clearly understood what 
is required of him, namely, that he should search the pile for the skeins making an 
impression on his chromatic sense similar to that made by the sample, and inde- 
pendently of any name he may give the color. Indeed, it is not desirable that he 
should be asked to name the colors, and he should be discouraged from doing so. 
The examiner should explain that resemblance in every respect is not necessary; 
that no two specimens are just alike ; that the only question is the resemblance of 
color ; and that, consequently, he must endeavor to find something lighter and 
darker of the same color. If the person examined cannot understand this verbal 
explanation, the examiner must resort to action. He must himself make the trial 
by searching with his two hands for the skeins, thereby showing what is meant by 
a shade, and afterward restoring the whole to the pile, except the sample skein. 
Or, when a large number of persons have to be examined together, it will be more 
rapid to begin at once with such a demonstration before the assemblage. There 
is no loss of security in this, for no one with defective chromatic sense finds the 
correct skeins in the pile any the more easily from the fact of having a moment 
before seen some one else looking for and arranging them. 

On the card which is attached to the inside of the back cover of this book 
there are two classes of wool samples : I. The test-samples, which are placed 
horizontally. 2. The colors of confusion — that is, those which the color-blind 
person selects from the heap of wools, because he confuses them with the color 
of the sample — and these are arranged vertically under their respective test-sam- 
ples. The object of this card is merely to illustrate this text. It cannot itself be 
used for testing the color-sense, nor does it contain all the colors and shades neces- 
sary for the purpose. 

The test is conducted as follows : Test I. The green sample is presented. 
This sample, as already explained, should be of the palest shade of very pure 
green, which is neither yellow-green nor blue-green to the normal eye, but fairly 
intermediate between the two. The examination must be continued until the 
person examined has selected all the other skeins of the same color, or else, with 
these or separately, one or several skeins of the class corresponding to the " colors 
of confusion" (i to 5), until he has sufficiently proved, by his manner of doing 
it, that he can easily and unerringly distinguish the confusion colors, or until he 
has given proof of unmistakable difficulty in accomplishing his task. He who 
places beside the sample one of the colors of confusion (i to 5) — that is to say, 
finds that it resembles the test-sample — is color-blind. He who, without being 
quite guilty of this confusion, evinces a manifest disposition to do so, has a feeble 
chromatic sense. 

If we want to know the kind and degree of the color-blindness which the fail- 
ure to perform Test /shows to be present, we must proceed to 

Test Ila. A purple skein is shown to the person being examined. The trial 
must be continued until he has selected all, or the greater part of the skeins of 
the same color, or else, simultaneously or separately, one or several skeins of 
"confusion " (6 to 9). He who confuses, selects either the light or deep shades 



6i2 APPENDIX. 

of blue and violet, especially the deep shades (6 and 7), or the light or deep 
shades of one kind of green or gray, inclining to blue (8 and 9). I. He who 
is color-blind by Test I, and who, upon Test Ila, selects only purple skeins, is 
termed " incompletely color-blind." 2. He who, in Test Ila, selects with pur- 
ple only blue and violet, or one of them, is " completely red-blind." 3. He 
who, in Test Ila, selects with purple only green and gray, or one of them, is 
" completely green-blind." The red-blind never selects the colors taken by the 
green-blind, or z'ice versa. Often the green-blind places a violet or blue skein 
beside the green, but only the brightest shades of these colors. This does not in- 
fluence the diagnosis. 

The examination may end here, and the diagnosis be regarded as settled. But 
to convince railway employers and ship-owners, and their employees, a still further 
trial may be made. It only serves to corroborate the diagnosis. 

Test lib. The red skein is presented. It is necessary to have a vivid red 
color, like the red flag used as signals on railways. This test, which is applied only 
to those either " com.pletely red-blind," or " completely green-blind," should be 
continued until the jierson examined has placed beside the specimen all the skeins 
belonging to this shade, or the greater part of them, or else, separately, one or 
several "colors of confusion " (10 to 13). Alongside the red, the red-blind 
places green and brown shades, which (10 and ll) to the normal sense seem 
darker than red. On the other hand, the green-blind selects opposite shades — 
those which appear lighter than red (12 and 13), Every case of complete color- 
blindness discovered does not always make the precise mistakes just mentioned 
with Tst lib. These exceptions are either persons with comparatively inferior 
degrees of complete color-blindness, or of color-blind persons who have been 
exercised in the colors of signals, and who try not to be discovered. They usu- 
ally, but not always, confound at least green and brown. Total color-blindness 
is extremely rare, but such a case would be recognized by a confusion of every 
color having the same intensity of light. 

Violet-blindness will be recognized by a genuine confusion of purple, red, and 
orange in Test lib. 

If further information on the subject be desired, the reader should consult Prof. 
Holmgren's original monograph, " De la Cecite des Couleurs," Stockholm, 1877, 
or Dr. Joy Jefl"ries' " Color-blindness," Boston, 1879. 



APPENDIX. 613 



APPENDIX 11. 

REGULATIONS AS TO DEFECTS OF VISION WHICH DISQUALIFY 
CANDIDATES FOR ADMISSION INTO THE CIVIL, NAVAL, 
AND MILITARY GOVERNMENT SERVICES, THE ROYAL 
IRISH CONSTABULARY, AND THE MERCANTILE MARINE. 

By an army circular issued by the War Office on September I, 1887, and 
which remains in force, candidates for commissions in the army are re- 
quired to possess the following visual powers. These regulations apply to all 
branches of service, including the Medical Department : 

Letters and numbers corresponding to Snellen's metrical test-types (Edition 
1885) will be used for testing the standard of vision. 

If a candidate's vision, measured by Snellen's test types, be such that he can 
read the types numbered D = 6 at six meters, or 20 English feet, and the types 
numbered D = 0.6 at any distance selected by himself, with each eye separ- 
ately, and without glasses, he will be considered fit. 

If a candidate cannot read with each eye separately, without glasses, Snellen's 
types marked D = 36 at a distance of six meters, or 20 English feet — i. e., if he 
does not possess one-sixth of Snellen's standard of normal acutenessof vision — al- 
though he may be able to read the types D = 0.6 at some distance with each eye, 
he will be considered unfit. 

If a candidate can read with each eye separately, Snellen's types, numbered 
D = 36, at a distance of six meters, or 20 English feet, without glasses, but can- 
not read them beyond that distance — /. e., if he just possesses one-sixth of normal 
acuteness of vision — and his visual deficiency is due to faulty refraction, he may 
be passed as fit, provided that, with the aid of correcting glasses, he can read 
Snellen's type D = 6 at six meters, or 20 English feet, with one eye, and at 
least Snellen's types D =r 12 at six meters, or 20 English feet, with the other 
eye ; and, at the same time, can read Snellen's type marked D == 0.8 with one 
or both eyes, without the aid of glasses, at any distance the candidate may 
select ; ?'. e.,a.s2i minimum a candidate must have with each eye separately V == ^^ 
without glasses ; as well, as V = | with one eye, and V = -^^ with the other eye, 
with glasses. 

Squint, inability to distinguish the principal colors, or any morbid condition, 
subject to the risk of aggravation or recurrence in either eye, will cause the rejec- 
tion of a candidate. 

The following are taken from Sir Joseph Fayrer's " Regulations as to Defects 
of Vision," etc. : * 



* Second edition, J. A. Churchill, 1887. 



6i4 APPENDIX. 

The Royal Navy. — i. A candidate is disqualified unless both eyes are 
emmetropic. The candidate's acuteness of vision and range of accommodation 
must be perfect. 

2. A candidate is disqualified by any imperfection of his color-sense. 

The author has it, on good authority, that no absolute rule as to vision is laid 
down with regard to candidates for entry into the Naval Medical Service. Each 
case is determined at the physical examination at the Naval Medical Department, 
which takes place shortly before the competition. 

Full normal vision is not necessarily essential in all cases for naval medical 
officers. 

3. Strabismus, or any defective action of the exterior muscles of the eyeball, 
disqualifies a candidate for the Royal Navy. 

The Home Civil Service. — With reference to the Home Civil Service, the 
Commissioners refer each case to a " competent medical adviser, leaving him to 
apply whatever tests he may deem suitable, and whatever standard the particular 
situation may require." 

The Indian Civil Service [Covenanted aud Uncovenanted). — I. A candidate 
may be admitted into the Civil Service of the Government of India, if ametropic 
in one or both eyes, provided that, with correcting lenses, the acuteness of vision 
be not less than | in one eye and | in the other, there being no morbid changes 
in the fundus of either eye. 

2. Cases of myopia, however, with a posterior staphyloma, may be admitted 
into the service, provided the ametropia in either eye do not exceed 2.5 D, and 
no active morbid changes of choroid or retina be present. 

3. A candidate who has a defect of vision arising from nebula of the cornea 
is disqualified if the sight of either eye be less than -^^ ; and in such a case the 
acuteness of vision in the better eye must equal |^, with or without glasses. 

4. Paralysis of one or more of the exterior muscles of the eyeball disqualifies 
a candidate for the Indian Civil Service. In the case of a candidate said to have 
been cured of strabismus by operation, but without restoration of binocular 
vision, if with correcting glasses the vision reach the above standard (l), and if 
the movement of each eye be good, the candidate may be passed. The same 
rule applies to the case of unequal ametropia without binocular vision, both eyes 
having full acuteness of vision with glasses, and good movement. 

The Indian Medical Service. — i. A candidate may be admitted into the 
Indian Medical Service if myopic to the extent of five D, provided that with cor- 
recting lenses his acuteness of vision in one eye equals ^^, and in the other |, 
there being no morbid changes in the fundus of the eyes. Cases of myopia, 
however, with a posterior staphyloma, may be admitted into the service, provided 
the ametropia in either eye does not exceed 2.5 D, the acuteness of vision with 
correcting glasses being equal to the above standard, and no active morbid 
changes of choroid or retina being present. 



APPENDIX. 615 

2. Myopic astigmatism does not disqualify a candidate for the service, provided 
the combined spheric or cylindric glasses required to correct the ametropia do 
not exceed — 5 D ; the acuteness of vision in one eye when so corrected being 
equal to ■^-^, and in the other eye f ; the accommodation being normal with the 
correcting glasses, and no progressive morbid changes of the choroid or retina 
being present. 

3. A candidate having total hypermetropia not exceeding five D is not disquali- 
fied for the service, provided the sight in one eye, when under the effect of atro- 
pin, equals y\, and in the other f, with -f- 5 D or any lower power. 

4. Hypermetropic astigmatism does not disqualify a candidate for the service, 
provided the combined lens required to correct the total hypermetropia does not 
exceed five D. The acuteness of vision in one eye must equal y^v, and in the 
other 1^, with or without the correcting glass. 

5. A candidate may be accepted with a faint nebula of one cornea, reducing 
the vision to y'v, provided the eye in other respects be healthy. In such a case 
the better eye must be emmetropic, and possess normal vision. Defects of vision 
arising from pathologic or other changes in the eye which are not referred to in 
the above rules may exclude a candidate for admission into the Indian Medical 
Service. 

6. A candidate is disqualified if he cannot distinguish the principal colors — 
red, green, violet or blue, yellow, and their various shades (dischromatopsia). 

7. Paralysis of one or more of the exterior muscles of the eyeball disqualifies 
a candidate for the Indian Medical Service. 

The Indian Marine Service [Inchiding Ejigineers and Firemen). — I. A 
candidate is disqualified if he has an error of refraction in one or both eyes 
which is not neutralized by a concave, or by a convex one D lens, or some lower 
power. 

2. A candidate is disqualified if he cannot distinguish the primary colors and 
their various shades — red, green, violet or blue, and yellow. 

3. Strabismus, or any defective action of the exterior muscles of the eyeball, 
disqualifies a candidate for the Marine Service. 

Royal Irish Constabulary. — Candidates for cadetship in the Royal Irish 
Constabulary and recruits must be able to read with each eye separately, and 
without glasses, Snellen's metrical test-types (Edition 1882) number D = 10, at 
20 English feet, and those numbered D =: 0.8 at any distance selected by the 
candidate himself. 

Squint, inability to distinguish the principal colors, or any morbid condition, 
liable to the risk of aggravation or recurrence in either eye, will involve the re- 
jection of the candidate. 

The British Mercantile Marine. — An appendix (Exn. i, Appendix T) to 
the regulations relating to the examinations of masters and mates in the Mercan- 



6i6 APPENDIX. 

tile Marine has been issued by the Board of Trade, and came into force on Sep- 
tember I, 1894. 

It is entitled " Form Vision, Color Vision, and Color Ignorance Tests," and 
enacts the following rules : 

1. Examinations for form vision, color vision, and color ignorance are open to 
all persons serving or intending to serve in the Mercantile Marine, and all such 
persons are recommended to take the earliest opportunity of ascertaining by means 
of these examinations whether their vision is such as to qualify them for service 
in that profession. 

2. The examination consists of three parts : 

{a) Form vision test, [d) Color vision test, [c) Color ignorance test. 

No candidate will be examined in the color vision test until he has passed the 
form vision test, or in the color ignorance test until he has passed the color vision 
test. 

3. Any person serving or intending to serve in the Mercantile Marine, if desir- 
ous of undergoing the form vision, color vision, and color ignorance test on/y, 
must make application to the Superintendent of a Mercantile Marine Office on 
the form EXN. 2A, and must pay a fee of one shilling. 

4. Every candidate for a certificate of competency who is not already in pos- 
session of such a certificate will be required to pass the three tests mentioned in 
Rule 2 before he can proceed to the examination in navigation and seamanship 
for the certificate which he desires to obtain, even though he may have passed 
the tests on some previous occasion. 

5. Every candidate who is already in possession of a certificate of com- 
petency, and who desires to obtain a certificate of a higher grade, will be re- 
quired to pass the three tests mentioned in Rule 2 before he can proceed to the 
examination in navigation and seamanship for the certificate of a higher grade ; 
that is to say, no candidate will be permitted to proceed with the examination 
in navigation and seamanship for a higher certificate if he fail to pass the three 
tests. 

6. If a candidate fail to pass any of the three tests a note of the fact of his 
having done so will be written across the face of the certificate which he already 
possesses before the certificate be returned to him. 

7. If a candidate who undergoes the form vision, color vision, and color ignor- 
ance tests on/}' (see Rule 3) be in possession of a certificate of competency, he 
must hand in his certificate before the examination commences, and if he fail to 
pass any of the three tests a statement of his failure will be written on the certi- 
ficate before it is returned to him. 

8. Candidates who fail to pass the form vision test or color ignorance test can 
be reexamined at intervals of three months, but candidates who fail to pass the 
color vision test cannot be reexamined. It is open, however, to any candidate 
who has failed to pass that test to appeal to the Board of Trade, who may, if 
they think fit, remit the case to a special examiner or body of examiners for final 
decision. 



APPENDIX. 617 

9. The expenses of candidates who are examined by the special examiners 
and are reported by them to have passed the three tests, will, under certain circum- 
stances, be paid by the Board of Trade, at a rate which will be notified to the 
candidate, but no payment whatever will be made toward the expenses of candi- 
dates who upon their own application are examined by the special examiners and 
are reported by them to have failed. The special examinations will be held in 
London only. 

10. When a candidate fails to pass the color test, the examiner will point out to 
him the conditions under which he can appeal. Appeals are to be made through 
the examiner, and forwarded to the Board of Trade with the examiner's remarks. 

11. The holder of a certificate which bears on it a statement of failure in the 
first test (form vision) or in the third test (color ignorance) can have the statement 
removed by passing, after the prescribed interval, the test to which it refers, but 
the instruction in the last paragraph of Rule 2 must be followed. 

12. The fee paid for examination for a certificate of competency includes the 
fee of one shilling for examination in form vision, color vision, and color ignor- 
ance, and if the candidate fails to past these tests, will, with the exception of one 
shilling, be returned to him. 

13. Only examiners who have themselves passed the color test are to under- 
take these examinations. 

For7n Vision Test. — The tests to be used are Snellen's letter test for candidates 
who can read, and the dot tests for those who cannot read. The sets of tests 
which have been supplied to the examiners consist respectively of eight sheets of 
Snellen's letters and two sheets of dots. 

Candidates may use both eyes or either eye when being tested, but they must 
not be allowed to use spectacles or glasses of any kind. If the candidate can 
read correctly, at a distance of 16 feet, three of the five letters in the fifth line 
from the top, or four of the letters in either of the two lines below, he may be 
considered to have passed the test. If he cannot do so he should be treated as 
having failed. 

If the candidate cannot read, he must be tested with the sheet of dots. For this 
test he is to be placed at a distance of precisely eight feet from the test sheets, 
and exactly opposite them. One of the sheets of dots is then to be exposed, and 
the candidate should be asked to name the number of dots in one or two of the 
lines or groups. Lines and groups of dots can be formed by holding a piece of 
white paper over part of the sheet, but care must be taken that when this is being 
done the candidate's view is not obstructed or the light on the test sheet in any 
way obscured. 

If the candidate answer the questions put to him by the examiner with com- 
plete or very nearly complete accuracy, he should be treated as having passed. If 
he does not answer with very nearly complete accuracy, he should be treated as 
having failed. 

Color Vision Test. — The color vision of candidates is to be tested by means of 
Holmgren's wools. 
52 



6i8 APPENDIX. 

Color Ignorance Test. — The object of this test is simply to ascertain whether 
the candidate knows the names of the three colors — red, green, and white — 
which it is important for every seaman to be acquainted with, and the test is to 
be confined to naming those colors. 

One or two of the purest red and green skeins should be selected from the set 
of wools, and the candidate should be required to name their colors. He should 
also be required to name the color of any white object, such as a piece of white 
paper. 

If he answer correctly, he should be considered to have passed the test. If he 
make any mistake he should be tried with the lantern which was formerly used 
for color tests, the plain glass, and the standard red and green glasses being em- 
ployed for the purpose. If he does not name these glasses correctly, he should be 
reported as having failed to pass the test. 



■1 



I 



NDEX. 



Accommodation, amplitude of, 21 ; 
anomalies of, 71 ; cramp of, 45, 
52, 76 ; and convergence, connec- ' 
tion between, 23 ; mechanism of, I 
20 ; normal, 19 ; paralysis of, 74 ; : 
relative, 23 ; relative amplitude 
of, 23 ; voluntary relaxation of the, 
80 

Accommodative asthenopia, 44, 45, 76, 

105, 315 
Acromegalia, 484 
Acuteness of vision, 30 
Adaptation of the retina, 28 (foot-note), 

443 

Adenoma of the eyelid, 220 

Advancement, operation of, for strabis- 
mus, 576 

Agraphia, 489 

Albinism, 313 

Albuminuria, 379, 429, 439, 442, 460 

Albuminuric retinitis, 428, 429, 455, 
460 

Alcoholism, 335, 464, 542 

Alexia, 488, 489 

Amaurosis, epileptiform, 456 ; pre- 
tended, 514; quinin, 442; spinal, 
470; supraorbital, 512, 590; tem- 
porary, after blepharospasm, 156 

Amblyopia, alcoholic, 335,464; cen- 
tral, 461, 462, 474 ; congenital, 372, 
512, 560; due to central lesions, 
475 ; exanopsia, 560 ; glycosuric, 
473 ; from hemorrhage (hemateme- 
sis, etc.), 472; hysteric, 509; from 
injury to supraorbital nerve, 512, 
590; nervous, 504; reflex, 512, 
590; in strabismus, 559; tobacco, 
333, 462 ; toxic, 462 ; uremic, 514 

Ametropia, 39 

Amnesia, optic, 490 

Amnesic color-blindness, 490 

Amplitude of accommodation, 21 ; of 
convergence, 24, 582; in hyperme- 



tropia, 42 ; in myopia, 48 ; in pres- 
byopia, 72 

Amyloid degeneration of the conjunc- 
tiva, 139 

Anemia, 437 ; progressive pernicious, 

437 

Aneurysm of carotid, 335, 599 ; of cen- 
tral retinal artery, 431, 441 ; orbital, 
600 

Angle, alpha, 25 ; gamma, 25 ; 
gamma in hypermetropia, 42 ; 
gamma in myopia, 49 ; the meter, 
24, 582 ; of strabismus, 565 ; the 
visual, 31 

Angular gyrus, 478, 489, 491 

Aniridia, 291, 295 

Anisometropia, 70 

Ankyloblepharon, 255 

Aortic regurgitation, 344 

Aphakia, 411 

Aphasia, 484, 485 

Apoplexy, cerebral, 333, 336, 488 ; of 
pons Varolii, 335 ; of retina, 436 

Arcus senilis, 208 

Argyll Robertson pupil, 334, 494, 500 

Argyrosis, 109 

Arthritis, gonorrheal, 135, 281 

Asthenopia, iio; accommodative, 44, 
45, 105; muscular, 580; nervous, 
504 ; retinal, 560 

Astigmatism, 39, 56 ; after cataract 
operations, 412 ; estimation of de- 
gree of, 62 ; irregular, 70, 400 ; len- 
tal, 69 ; ophthalmoscopic diagnosis 
of, 61, 89, 96; regular, 56; retin- 
oscopy in, 96 ; spectacles in, 62 ; 
symptoms of, 59 

Astigmometer, the, 66 

Ataxia, locomotor (seeTahes Dorsalis), 
ocular, 500 ; hereditary, 502, 586 
(foot-note) 

Ataxic paraplegia, 586 (foot-note) 

Atheroma, general, 428, 437, 439, 441 



619 



620 



INDEX. 



Athetosis, 486 

Atrophy, progressive muscular, 335, 

586 (foot-note) 
Atropin, 44, 75, 89, no, 159, 167, 

172, 173, 175, 176, 179. 190, 192, 
210, 279, 286, 332, 370; danger of 
glaucoma from use of, 287,356, 360, 
369 ; poisoning, 286, ^^3 



Binocular field, 36; vision, 569, 570 
(foot-note) 

Bisulphid of carbon, amblyopia from, 
464 

Black eye, 258 

Blennorrhea of the conjunctiva, 1 14, 
115, 125, 174; of the lacrimal sac, 
262; neonatorum, 125; prophylaxis 
of, 128 

Blepharitis, intermarginal, 106 ; mar- 
ginal, 214, 236, 260, 267 ; squa- 
mosa, 214; ulcerosa, 214 

Blepharophimosis, 234 

Blepharoptosis [see Ptosis) 

Blepharospasm, 156, 160, 221 

Blind spot, the, 37 

Blow on the eye, 76, 257, 276, 290, 

377, 37^, 410, 415 > 450, 454, 47 1 

Brain, localization of disease in the, 
230, 484, 547 ; ocular diseases and 
symptoms in focal disease of the, 
475 ; in diffuse disease of the, 481 

Breast, cancer of the, 311 

Broca's lobe, lesion of, 490 

Bronchitis, 307 

Bulbar paralysis, 75, 542, 543 

Buphthalmia, 362 



Canaliculus, obstruction of the, 261 

Canthoplasty, 124, 235 

Capsule, lesion of the internal, 230, 
484, 486 

Capsulotomy, 390, 408 

Carcinoma of the breast, 31 1 ; of the 
choroid, 311 ; of the ciliary body, 
202; of the orbit, 598 

Caries of nasal bones, 267 

Cataract, 46, 50, 301, 305, 316, 363 ; 
adherent (or accreta), 376; anterior 
polar, or pyramidal, I35, 374 ; arti- 
ficial ripening of, 370; black, 372; 
calcareous, 376 ; capsular, 376 ; cen- 
tral capsular, 135 ; central lental, 



373 ; complete, 36^ 



iplete, of 



young people, 371 ; congenital, 304, 
372, 373 ; diabetic, 371 ; discission 
for, 405 ; extraction of, without iri- 
dectomy, 400; fusiform, 375 ; linear 
operation for, 381, 407 ; Morgagnian, 
366 ; myopia in incipient, 50, 368 ; 
operations for, 379 ; partial, 373 ; 
posterior polar, 375 ; ripeness of, 
365 ; secondary, 375, 408 ; senile, 
363 ; spectacles after extraction of, 
411 ; in incipient, 369; suction op- 
eration for, 407 ; symptoms of, 367 ; 
three millimeter flap-operation for, 
387 ; traumatic, 376 ; treatment of, 
369 ; von Graefe's operation for, 
385 ; zonular or lamellar, 373, 406 
Catarrh, conjunctival, 106; spring, in 
Cautery, the actual, 159, 169, 174, 176, 

178, 186, 213 
Cavernous sinus, thrombosis of the, 

336, 550 

Cerebellum, tumor of the, 456 (foot- 
note), 552 

Cerebral abscess, 456 ; cysts, 457 ; dis- 
ease, 222, 230, 456, 472, 491 ; em- 
bolism, 333 ; hemorrhage, 481, 485, 
487; localization, 230, 483, 491, 
547 ; tumor, 456, 493, 497, 551 

Chalazion, 217 

Chemosis, 105, no, 126, 128, 217 

Chiasma, lesion of the, 481, 483 

Chloroform narcosis, the pupil in, 233 

Chlorosis, 216, 336, 459 

Choked disc, 455 

Cholera, Asiatic, 609 

Cholesterin in vitreous humor, 418 

Chorea, 439, 498 

Choroid, central senile atrophy of the, 
305, 376 ; colloid degeneration of 
the, 304 ; coloboma of the, 295, 313 ; 
congenital defects of the, 313; de- 
tachment of the, 307 ; diseases of 
the, 302 ; hemorrhage in the, 305 ; 
injuries of the, 309 ; tubercle of the 
293, 311, 447 ; tumors of the, 310, 
450 ; ring, lOO 

Choroiditis, 274, 302; central, 305, 
380 ; central senile guttate, 304 ; 
disseminated, 278, 302, 375, 426, 
427 ; purulent, 305 

Choroidoretinitis, 304, 308, 426 

Chromidrosis, palpebral, 220 

Ciliary body, coloboma of the, 295, 
313; diseases of the, 299; inflamma- 
tion of the, 299 ; injuries of the. 



INDEX. 



621 



301 ; new growths of the, 302 ; ' 
muscle, action of the, 20 ; cramp of 
the, 43, 46, 52. 76 

Climacteric, the, 437, 459 

Cocain, 152, 164, 176, 183, 203, 332, 
364 (foot-note), 385 

Coloboma, congenital, of the choroid, 
295,313; of the ciliaiy body, 295, 
313; of the crystalline lens, 295, I 
313 ; of the eyelids, 259 ; of the iris, | 

295,313 

Color-blindness, 28, 463, 469, 474, 
491 ; amnesic, 490 

Color-sense, the, 26, 28, 610 ; in peri- 
phery of field, 37 ; method of testing 
the, 28, 610 ; theories of the, 28 

Commotio retinae, 454 

Congestion papilla, 430, 455 ■ 

Conic cornea, 46, 199 ! 

Conjugate lateral paralysis, 493, 543 | 

Conjunctiva, amyloid degeneration of 
the, 139 ; cysticercus under the, 150; 
cyst of the, 149 ; dermoid tumor of 
the, 147 ; diseases of the, 105 ; epi- 
thelioma of the, 148, 149 ; essential 
shrinking of the, 143 ; hemorrhages 
in the, 107, 139, 147 ; hyaline de- 
generation of the, 139 ; hyperemia i 
of the, 105 ; injections of sublimate 
solution under the, 177 ; injuries of 
the, 151 ; lipoma of the, 148 ; lithi- 
asis of the, 150 ; lupus of the, 141 ; 
lymphoma of the, 125 ; nevus of 
the, 147 ; papilloma of the, 148 ; 
pemphigus of the, 141, 142 ; 
Pinguecula of the, 145, 146; poly- 
pus of the, 147 ; sarcoma of the, 
149 ; syphilitic disease of the, 148 ; ' 
transplantation of the, 233 ; tubercu- 
lar disease of the, 139, 212 ; uric 
acid in the, 151 ; xerosis of the, 
142, 180 

Conjunctival complication of small-pox, 

137 

Conjunctivitis, 106; catarrhal, 106, , 
266, 271 ; croupous, 135, 142 ; diph- 
theric, 136, 142, 163; follicular, 
109 ; gonorrheal, 125 ; granular, 
III, 231, 236; phlyctenular, 153; 
purulent, 125, 163, 167, 174, 235 

Contact glasses, 200 

Convergence, loss of power of, 493, 
500 

Corectopia, 295 

Cornea, abscess of the, 127, 163, 175, I 

53 



186, 205 ; absorption ulcer of the, 
178 ; arcus senilis in the, 208 ; bulla 
of the, 184 ; calcareous film of the, 



cauterization of the, 159, 169, 
176, 178; cicatrices in the, 
165, 172, 178 ; conic, 46, 
deep ulcer of the, 127, 132, 
173 ; dermoid tumor of the, 147, 
diagnosis of ulcer of the, 164; 



193; 
174, 
161, 

199; 

137,] 

20z 

diseases of the, 162 ; ectasies of the, 
194; epithelioma of the, 202; fa- 
cetted ulcer of the, 178 ; fibroma of 
the, 202 ; foreign bodies in the, 179, 
203 ; globosa, 362 ; herpes of the, 
181 ; infantile ulceration of the, with 
xerophthalmia, 180 ; inflammations of 
the, 162 ; injuries of the, 162, 173, 
174, 175, 203, 360 ; leukoma of the, 
167, 174, 175, 205 ; macula of the, 
167, 205 ; marginal ulcer of the, 
127, 132, 138, 145 ; nebula of 
the, 167, 205 ; non-ulcerative inflam- 
mations of the, 186; opacities of the, 
99, 167, 205 ; papilloma of the, 
202 ; paracentesis of the, 133, 158, 
170, 174, 178, 201, 289 ; phlyctenu- 
lar disease of the, 153, 155, 163 ; 
pigmentation of the, 209 ; ring ulcer 
of the, 127, 155, 178; rodent ulcer 
of the, 177 ; sarcoma of the, 202; 
sclerotizing opacity of the, 193, 274; 
simple ulcer of the, 173 ; staphyloma 
of the, 118, 133, 142, 172, 174, 175, 
194, 230; tattooing of .the, 206; 
transplantation of the, 207 ; tumors 
of the, 202 ; ulcerative inflammations 
of the, 162, 193 ; ulcus serpens of 
the, 174, 187, 205 

Corneal complications in catarrhal con- 
junctivitis, 106 ; in conjunctival pem- 
phigus, 141 ; in diphtheric conjunc- 
tivitis, 137 ; in purulent conjunctivitis, 
127, 132, 174 ; in small-pox, 137 ; in 
trachoma, 115 

Corpus quadrigeminum, lesion of the, 
486 

Corrosive sublimate, subconjunctival in- 
jections of, 177, 273, 317 

Cramp of accommodation, 43, 45^ 52, 
76; of orbicularis, 156, 220, 243 

Croupous conjunctivitis, 135, 142 

Crus cerebri, lesion of the, 487, 548 

Cupping, pathologic, of the optic disc, 
loi, 341 ; physiologic, of the optic 
disc, 100 



622 



INDEX. 



Cyclitis, 191, 211, 278, 299, 301 

Cyst, Meibomian, 217 ; of the conjunc- 
tiva, 149 ; of the iris, 292 

Cysticercus in the vitreous humor, 422 ; 
under tlie conjunctiva, 150; under 
the retina, 422, 448 

Cystoid cicatrix, 353, 400 



Dacryoadenitis, 269 

Dacryocystitis, acute, 124, 267 ; chronic, 
175, 269 

Daturin, 332 

Decentration of spectacle glasses, 583 

Dermoid tumors of conjunctiva and 
cornea, 147, 202 

Diabetes, 50, 75, 147, 285, 288, 371, 
379, 432, 464, 542 

Dilator pupillse, 329 

Dioptric unit, the, 17 ; system of the 
eye, 18 

Dioptry, the, 17 

Diphtherial paralysis of accommoda- 
tion, 75 ; of orbital muscles, 542 

Diphtheric conjunctivitis, 135, 136, 
142, 143 

Diplopia in convergent concomitant 
strabismus, 558, 568 ; crossed, 528 ; 
homonymous, 526; in insufficiency 
of the internal recti, 580 ; in paraly- 
sis of orbital muscles, 525 ; monocu- 
lar, 290, 411 

Discission, 372, 374, 405 

Distichiasis, 117, 235 

Duboisin, 332 

Dyslexia, 489 



Eccentric vision, 33 

Ecchymosis of the conjunctiva, 107, 

Eclipses, blinding of the retina in, 443 

Ectropion, 250, 590 

Eczema, 153, 154, 156, 157, 214 

Egyptian ophthalmia, 1 14 

Electric light, effects of, on the eyes, 

445 

Electrolysis for detached retina, 453 ; 
for nevi, 219 ; for stricture of canali- 
culus, 262 ; for trichiasis, 236 

Embolism, cerebral, ;^;^;^, 498 ; of retinal 
vessels, 425, 429, 434,438,440, 469 

Emmetropia, 19 ; amplitude of accom- 
modation in, 21 

Encephalocele, 601 



Encephalopathia saturnina, 496 

Endarteritis, 442 

Endocarditis, 307, 439 

Enophthalmos, 609 

Entropion, 117, 236, 243 

Enucleation of the eyeball, 319, 323 

Epicanthus, 258 

Epilation of eyelashes, 236 

Epilepsy, 61, 147, 333, 497, 580 

Epiphora, 260, 266 

Episcleritis, 271 ; periodic transient, 

273 

Epithelioma of the conjunctiva, 148, 
149 ; of the cornea, 202 ; of the eye- 
lid, 220 

Erysipelas of the eyelids, 210, 268, 

441, 458 
Erythropsia, 516 
Eserin, no, 131, 134, 168, 172, 176, 

178, 201, 202,332, 353, 388 
Evisceration of the eyeball, 196, 318 
Exophthalmic goiter, 230, 344, 544, 6oi 
Exophthalmos, pulsating, 599 
Expression of granulations, 121 
Eyeballs, the motions of the, and their 

derangements, 518 
Eyelashes, lice of the, 216, 
Eyelids, adenoma of the, 220 ; chromi- 
drosis of the, 220 ; coloboma of 
the, 259; cramp of the, 156, 221, 
243 ; diseases of the, 210; ecchymo- 
sis of the, 258 ; eczema of the, 210, 
214; emphysema of the, 257; epi- 
thelioma of the, 220 ; erysipelas of 
the, 210, 268, 441, 458 ; eversion of 
the, 250; herpes zoster of the, 211 ; 
injuries of the, 257 ; inversion of the, 
243 ; lupus of the, 220 ; millium of 
the, 218; molluscum of the, 218; 
nevus of the, 219 ; restoration of an, 
256 ; rodent ulcer of the, 213 ; sar- 
coma of the, 220 ; syphilitic sores on 
the, 211, 212; vaccine vesicles on 
the, 212 



Facet on the cornea, 161, 178 
Facial center, lesion of the, 230 
Far point and near point, 20, 47 
Field of vision, 33 ; binocular, 36 
Fifth nerve paralysis, 179, 553 
Fixation, field of, 523 ; line of, 25 
Fluorescin, 164, 169, 177 
Focal illumination, 99 ; interval, 57 
Follicular conjunctivitis, 109 



INDEX. 



623 



Fomentations, warm, 168, 288, 289 
Form-sense, the, 30, 38, 476, 485 
Fornix conjunctivae, 105 
Fourth nerve, paralysis of the, 530, 
551 ; ventricle, diseases of floor of, 

75 
Fovea centralis, 102, 104 
Fracture of the orbit, 258 
Fundus oculi, the normal, 99, 102 



Geniculate body, lesion of the, 486 
Glaucoma, 27, 139, 185, 193, 338, 
376, 490 ; acute, 345 ; chronic, 340 ; 
etiology of, 348 ; fulminans, 348 ; 
hemorrhagic, 361, 438; pathology 
of, 349 ; primary, 338 ; secondary, 
274, 282, 284, 292, 300, 310, 321, 

360, 377» 404, 407, 447, 490, 505 ; 
subacute, 348 ; treatment of, 352 

Glaucomatous cup, 341, 343 ; degen- 
eration, 347, 359; ring, 343 

Glioma of the brain, 447, 456 ; of the 
optic nerve, 447 ; of the retina, 306, 
312, 414, 446 _ _ 

Gonorrheal arthritis, 135, 281 ; conjunc- 
tivitis, 125 ; iritis, 281 

Gout, 273, 437 

Granular conjunctivitis [se^ Trachoma) 

Granuloma of the iris, 292 



Hallucinations, visual, 490 

Hay-fever, ill 

Headache, 61 

Heart, disease of the, 344, 428, 430, 

437, 439,.44i 

Hematemesis, 437, 472 

Hemiachromatopsia, 481, 483, 485, 
487 

Hemianesthesia, 486, 489 

Hemianopia, 475, 480, 483, 491, 547 ; 
altitudinal, 477 ; complete and par- 
tial, 476 ; homonymous, 327, 476, 
484, 489, 506 ; localization of lesion 
in, 483 ; nasal, 477, 483 ; relative 
and absolute, 476, 480 ; superior and 
inferior, 477, 480, 483 ; temporal, 
477,483; transitory, 485, 511 

Hemiopic pupil, the, 487 

Hemiplegia, 484, 487 ; crossed, 230, 
549, 552, 553 

Hemophthalmos, 275 

Hemorrhage into the anterior chamber, 
275, 288 



Hemorrhoids, 429 

Hering's drop experiment, 570 (foot- 
note) ; theory of the color-sense, 28 

Hernia cerebri, 6co 

Herpes cornse, 181 ; zoster ophthal- 
micus, 181, 211 

Heterophthalmos, 295 

Hippus, 328, 336 

Holmgren's tests for color-blindness, 
29 ; Appendix I 

Hordeolum, 217 

Hot eye, 273 

Hyaline degeneration of the conjunc- 
tiva, 139 

Hydrocephalus, 458, 467, 469, 495, 

'543 

Hydrophthalmos, 362 

Hyoscyamin, 332 

Hypermetropia, 39, 215 ; amplitude 
of accommodation in, 42 ; angle 
} in, 42 ; asthenopia in, 44, 45 ; 
axial, 39 ; cramp of ciliary muscle 
in, 43; curvature, 39; determina- 
tion of degree of, 41, 87, 96, 98; 
direct ophthalmoscopic method in, 
88; internal strabismus in, 45 ; latent 
43, 45 ; manifest, 43, 45 ; prescrib- 
ing of spectacles in, 45 ; retinoscopy 

in, 93, 95, 97 
Hypermetropic astigmatism, 58, 215 
Hyphemia, 275, 290 
Hypopyon, 155, 159, 165, 168, 174, 

175, 182, 186, 299, 300,306,419 
Hysteria, 220, 221, S33, 493, 504, 509, 

540 



Illaqueation, 237 

Illumination, focal, 99 

Image, erect ophthalmoscopic, 79 ; in- 
verted ophthalmoscopic, 81 

Influenza, epidemic, 75, 542 

Intermittent fever, 182 

Internal capsule, lesion of the, 230, 486 ; 
recti, insufficiency of the, 51 

Intestinal worms, 336 

Intracranial tumor, 430 

Intraocular injections, 317 ; tension, 
131, 282, 284, 288, 296, 300, 310, 
338, 378, 407 

Iridectomy, 296, 352 ; for glaucoma, 
296, 298, 352, 437; in cataract 
operations, 389 ; optic, 295, 298, 374, 
400, 406 

Irideremia, 295 



624 



INDEX. 



Iridochoroiditis, 138, 285, 292, 314, 400 

Iridocyclitis, 139, 175, 185, 191, 193, 
278, 282, 285, 293, 294, 314, 424 

Iridodialysis, 290 

Iridodonesis, 411 

Iridoplegia, 336 

Iridotomy, 299, 410 

Iris, absence of the, 291, anteversion of 
the, 291 ; coloboma of the, 295, 313 ; 
cysts of the, 292 ; diseases of the, 
278 ; foreign bodies in the, 290 ; 
granuloma of the, 292; injuries of 
the, 289 ; malformations of the, 295 ; 
new growths in the, 292 ; operations 
on the, 296 ; persistent pupillary 
membrane of the, 295 ; posterior 
limiting membrane of the, 329 ; pro- 
lapse of the, 132, 134, 171, 180, 360, 
401 ; retroflexion of the, 291 ; rup- 
ture of the sphincter of the, 291 ; 
sarcoma of the, 294 ; trembling of the 
iris, 417 ; tubercle of the, 292 

Iritis, 107, 118, 121, 132, 139, 167, 
168, 175, 182, 186, 188, 193, 211, 
274, 278, 279, 292, 361, 370, 372, 
377, 399, 407, 408; diabetic, 285 ; 
gonorrheal, 281 ; quiet, 281 ; rheu- 
matic, 281, 288 ; serous, 288; syphil- 
itic, 281, 283, 292 ; tubercular, 285, 
292 ; treatment of, 286 



Jacob's ulcer, 213 
Jequirity, 123 



Keratitis, 139, 153, 155, 163 ; bul- 
losa, 184; dendriform, 185; diffuse 
interstitial, 139 ; fascicular, 155, 159 ; 
filamentous, 183 ; neuroparalytic, 
179, 553; phlyctenular, 153, 155, 
178, 179; punctata, 191,192, 282, 
293, 300, 315 ; ribbon-like, 193 ; 
striped, 398 

Keratoconus, 199 



Lacrimal apparatus, diseases of the 
260; canaliculus, obstruction of the, 
261 ; duct, stricture of the, 263; 
fistula, 269 ; gland, extirpation of the, 
269, 270 ; hypertrophy of the, 270 ; 
inflammation of the, 269 ; obstruction, 
105, 216, 261, 262 ; tumors of the, 
600; punctum, eversion of the, 107, 



210, 250, 260; inversion of the, 260; 
malposition of the, 260 ; occlusion 
of the, 260; stenosis of the, 105, 
260, 261 ; sac, acute inflammation 
of the, 124, 267 ; blennorrhea of 
the, 262; mucocele of the, 266; 
obliteration of the, 269 

Lagophthalmos, 230 

Lamellar cataract, 373, 407 

Lamina cribrosa, 100 

Lead-poisoning, 460, 496, 542 

Lens, crystalline, absence of the, 41 1 ; 
calcification of the, 285 ; change of, 
in accommodation, 20 ; change of, in 
presbyopia, 71 ; coloboma of the, 
295, 313 ; diseases of the, 361 ; dis- 
location of the, 276, 314, 361, 376, 
410 ; injuries to the, 361, 376 ; re- 
moval of, in myopia, 54 

Lenses, cylindric, 62 ; numbering of 
the trial, 17 ; hyperbolic, 200 

Lental astigmatism, 69 

Lenticonus, 411 

Lenticular nucleus, lesion of the, 488 

Leukocythemia, 432 

Leukoma, 167 ; adherent, 133, 205 

Lice on the eyelashes, 216 

Light difference, 26 ; minimum, 26 ; 
projection of, 380 

Light-sense, the, 26, 343, 427, 435, 
443, 468,476,485 

Limbus conjunctivas, 105 

Lipoma of the conjunctiva, 148 

Lithiasis of the conjunctiva, 150 

Localization, cerebral, 230, 483, 491, 

547 
Locomotor ataxia [see Tabes Dorsalis) 
Lupus of the conjunctiva, 141 ; of the 

eyelid, 220, 256 



Macula corneae, 169, 205 ; lutea, 
disease of the, 51 ; nervous supply 
of, 481 ; normal appearances of the, 
loi, 104; ophthalmoscopic examina- 
tion of the, 84 

Madarosis, 212 

Maddox rod test, 582 

Magnet, the, for removal of foreign 
bodies in the cornea, 204 ; in the 
vitreous humor, 420, 421 

Malaria, 273,425,462 

Mania, acute, 335, 336 

Massage, III, 205, 272, 371, 440 

Measles, 107, 187, 307, 462 



INDEX. 



625 



Media, opacities in the, 98 ; the intra- | 
ocular, 18 ; the refracting, 18 j 

IMegalopsia, 303 

Meibomian cyst, 217 

Melancholia, 336 

Meningitis, 307, 324, 457, 483, 494, 
551, 587; cerebrospinal, 307,457, 
495 ; following enucleation, 307 ; 
traumatic, 495 ; tubercular, 457,495 

Meningocele, 600 

Menstruation, 274, 429, 437, 459 

Mental derangement, sign of, 75, 336; 
after cataract operation, 404 

Metamorphopsia, 303, 427, 444 

Meter angle, 24, 582 

Metria, 285, 307, 434, 587 

Metric system of numbering lenses, 17 

Meynert's fibers, 326, 487 

Micropsia, 75, 303, 427 

Migraine, 511, ophthalmoplegic, 539 

Military ophthalmia, ill 

Milium, 218 

Mind-blindness, 487, 490, 494 

Miosis, SS3 ; spinal, 334 

Miotics, action of the, 332 ; use of, in 
glaucoma, 358 

Mirror, concave, in retinoscopy, 90 ; 
plane, in retinoscopy, 97 

Molluscum, 218 

Morphin, action of, on the pupil, 332 

Motions of the eyeballs, 518 

Mouches volantes, 417 

Mucocele, 266 

Mules' operation, 197, 318 

Muscae volitantes, 367, 417 

Muscarin, 332 

Mydriasis, 75, 335, 587; traumatic, 
291 

Mydriatics, action of the, 322 

Myelitis, 335, 457, 502, 503 

Myodesopsia, 417 

Myopia, 45, 205, 274,423, 450; am- 
plitude of accommodation in, 48 ; 
angle 7 in, 49 ; apparent, 43 ; axial, 
45 ; cause of, 49 ; in incipient catar- 
act, 50; complications of, 51, 423, 
450 ; cramp of accommodation in, 
52; curvature, 46; detachment of 
retina in, 51, 450; determination of 
the degree of, 48, 87, 92; in dia- 
betes, 50 ; direct ophthalmoscopic 
method in, 87 ; insufficiency of the 
internal recti in, 51, 557, 579 ; mac- 
ular disease in, 51 ; management of, 
52 ; opacities in vitreous humor, 51 ; 



operative cure of, 54 ; posterior sta- 
phyloma in, 51 ; prescribing of spec- 
tacles in, 53; progressive, 51 ; re- 
tinal hemorrhage in , 5 1 ; retinoscopy 
in, 93, 94, 95 . 
Myopic astigmatism, 58 
Myosarcoma of ciliary body, 302 
Myotonia congenita, 502 



Nasal catarrh, 182, 263, 266; duct, 

stricture of the, 263, 265 
Near point, 20 
Nebula of cornea, 205 
Nephritis, 514 
Nerve-fibers, opaque, loi 
Neurasthenia, 336, 504, 507 
Neurectomy, optic, 520, 324, 360 
Neuroretinitis, 426 
Neurosis, traumatic, 504, 510 
Neurotomy, optic, 320 
Nevus of the conjunctiva, 147 ; of the 

eyelids, 219 
Nicotin, 332, 464, 542 
Night-blindness, 144, 303, 427, 435, 

443. 513 
Nuclear paralysis, 492, 500, 540 
Nyctalopia [see Night-blindness) 
Nystagmus, 313, 493, 585 



Objects, distant and near, 18 

Occipital lobe, lesion of the, 484, 491 

Ointment, yellow oxid of mercury, 158 

Omphalophlebitis, 307 

Opaque nerve-fibers, loi 

Ophthalmia, Egyptian, 114; gonor- 
rheal, 126; granular (i-^^ Trachoma); 
military, III ; neonatorum, 125 ; 
nodosa, 294 ; phlyctenular, 155 ; 
purulent, 125, 235 ; tarsi, 214 

Ophthalmoplegia externa, 493, 500, 
540 ; interna, 74, 541 

Ophthalmoscope, the, 77; direct method 
of examination by, 79 ; estimation of 
refraction with the, 84 ; indirect 
method of examination by the, 81 

Optic amnesia, 490 ; axis, the, 18, 25 ; 
center, the, 18; ganglia, lesion of 
the primary, 486, 488; nerve, the, 
83, 100 ; atrophy of the, 27, 30, 
210, 279, 343, 355, 443, 458, 467, 
471, 472, 474, 483, 487, 492, 494, 
499, 205, 587, 589; colloid out- 
growths of the, 471 ; diseases of the, 



626 



INDEX. 



455 ; injuries of the, 472 ; ophthal- 
moscopic examination of the, 83 ; 
resection of the, 320, 325 ; tumors of 
the, 470 ; neuritis, witli dropping of 
watery fluid from nostril, 466 ; pa- 
pilla, 83, 99 ; cupping of the, loo, 
341, 343 ; radiations, lesions of the, 
484, 486 ; neuritis, 279, 315, 455, 
467, 483, 487, 494, 502, 587 ; retro- 
bulbar, 459, 461, 474; tract, lesion 
of an, 484, 495 

Orbicular sign, the, 553 

Orbit, aneurysm of the, 599 ; carcinoma 
and sarcoma of the, 598 ; caries of 
the, 458, 589; cysts of the, 597; 
diseases of neighboring cavities, 594 ; 
diseases of the, 587 ; exostosis of 
the, 598 ; foreign bodies in the, 590 ; 
fracture of the, 528, 590 ; inflamma- 
tion in the, 458 ; injuries of the, 
589, 590 ; penetrating wounds of the, 
590 ; periostitis of the, 458, 588 ; 
syphilitic gumma of the, 588; tu- 
mors of the, 230, 458, 591 

Orbital cellulitis, 441, 587; muscles, 
paralysis of the, 492, 494, 499, 

524 
Osteosarcoma of the choroid, 312 
Ozena, 266 



Pannus, 117, 140, 149, 179 

Panophthalmitis, 138, 180, 276, 306, 
314, 414, 434 

Papillitis, 455 

Papilloma of conjunctiva, 148 

Paracentesis of the cornea, 132, 158, 
170, 174, 178, 201, 289, 439, 441 

Parallax, lOO, 342 

Parallel rays, 19 

Paralysis of accommodation, 74 ; 
acute ascending, 503 ; agitans, 496 ; 
bulbar, 75, 335, 543; of the cervical 
sympathetic, 335 ; conjugate lateral, 
543, 545 ; crossed, 230 ; diphtheric, 
75, 542; of the facial nerve, 230, 
552 ; fascicular, 547 ; of the fifth 
nerve, 179, 553; of the fourth nerve, 
530, 551 ; general, of the insane, 
335. 33^, 470, 494, 544; infantile, 
496 ; intermittent, of the third nerve, 
539 ; of the levator palpebrce {st'e 
Ptosis) ; nuclear, 541 ; of the oibital 
muscles, 524; of the sixth nerve, 
74, 528, 551 ; of the sphincter iridis 



461, 500, 542, 



154, 
153, 



(see Mydriasis) ; of the third nerve, 

74,533,547, 55i 

Pemphigus of the conjunctiva, 141, 
142, 231 

Perimeter, the, ;^2 

Peripheral neuritis, 
586 (foot-note) 

Peritomy, 124 

Perivasculitis, 442 

Phlyctenular conjunctivitis, 149, 
155, 210, 215, 221; keratitis, 
155, 163, 173, 178, 182, 184 

Phosphene, 450 

Photometer, 26 

Photophobia, ill, 118, 126, 156 

Phtheiriasis ciliorum, 216 

Phthisis anterior, 316 ; bulbi, 276, 285, 
292, 306, 308, 316 

Physostigmin, 332 

Pilocarpin, 168, 332 

Pineal gland, tumor of the, 551 

Pinguecula, 145, 146 

Pituitary body, 484 

Pneumonia, 180, 182, 285 

Polycoria, 295 

Polyopia, monocular, 368 

Polypus of the conjunctiva, 147 

Pons, lesions of the, 230, 335, 543, 548 

Posterior staphyloma, 51 

Pregnancy, 429, 431, 439, 514 

Presbyopia, 71 

Primary optic ganglia, lesion of the, 
486 

Prism in diplopia, 538 

Progressive muscular atrophy, 543, 
586 (foot-note) 

Proptosis, 588 

Pseudoglioma, 306, 414, 447 

Pterygium, 1 44 

Ptosis, 221, 258, 537, 547 ; operations 
for, 222 ; with associated movements, 
229 

Pulmonary obstruction, 425 

Pulsation in retinal vessels, 104, 343, 
348, 439, 603 

Pulvinar, lesion in the, 484, 486 

Punctum lacrimale, eversion of the, 
107, 210, 250, 260; inversion of 
the, 260 ; occlusion of the, 260 ; 
proximum, 21, 72 ; remotum, 20, 47 

Pupil, action of mydriatics on the, 
332 ; action of miotics on the, 332 ; 
the Argyll Robertson, 334; artificial, 
295, 321 ; change of, in accommo- 
dation, 20, 329; contraction of the, 



INDEX. 



627 



326 ; in chloroform narcosis, 333 ; 
dilatation of the, 75, 291, 329; ex- 
clusion of the, 281 hemiopic, 487 ; 
hippus of the, 328 ; influence of the 
fifth nerve on the, 332 ; of the optic 
nerve on the, 326 ; of the sympa- 
thetic nerve on the, 330 ; of the 
third nerve on the, 326, 327 ; mal- 
position of the, 295 ; occlusion of 
the, 281 ; reflex contraction of the, 
326; size of the, in disease, ^^t,^ 
494, 500 ; in health, 326 ; supernu- 
merary, 295 ; unrest of the, 331 

Pupillary membrane, persistent, 295 

Pyemia, 139, 307 



QuiNiN amaurosis, 425, 442 



Railway spine, 503 

Recurrent fever, 285 

Red vision [see Erythropsia) 

Refraction and accommodation, 18; 
abnormal, 39; normal, 19; estima- 
tion of, by retinoscopy, 90 ; by the 
upright image, 83 

Relative accommodation, 23 

Resection of the optic nerve, 320, 324 

Retina, adaptation of the, 28 (foot-note), 
443 ; alterations in vascularity of 
the, 425 ; aneurysm of the central 
artery of the, 441 ; apoplexy of the, 
436 ; atrophy of the, 435 ; blinding 
of the, by direct sunlight, 443 ; cys- 
ticercus under the, 422, 448 ; de- 
tachment of the, 51, 285, 308, 310, 
376, 415, 417, 423, 431, 438, 448 ; 
development of connective tissue in 
the, 433 ; diseases of the, 425 ; 
electric light, action of, on the, 445 ; 
embolism of the central artery of 
the, 438, 468 ; glioma of the, 312, 
446; hemorrhage in the, 51, 139, 
361, 428, 432, 433, 434, 436; in- 
flammation of the, 425 ; normal, 
loi ; septic afl'ections of the, 139, 
434 ; thrombosis of the central ar- 
tery of the, 440 ; thrombosis of the 
central vein of the, 425, 428, 440 ; 
traumatic edema of the, 454 ; trau- 
matic anesthesia of the, 454 ; tumor 
of the, 446 ; parasitic disease of the, 
448 



Retinal affections in diabetes, 432 ; 
vessels, the, 102, 425 ; diseases of 
the, 436; pulsation of the, 104, 343, 
348, 438, 603 ; sclerosis of the, 442 

Retinitis, 279, 423 ; albuminuric, 428, 
429, 455, 460 ; circinata, 434; hem- 
orrhagic, 428, 434 ; leukemic, 432 ; 
pigmentosa, 375, 435, 469, 513; 
proliferans, 433 ; punctata albescens, 
433 ; purulent, 434 ; syphilitic, 426, 
429 

Retinoscopy, 90 

Retrobulbar neuritis, 459, 462 

Rheumatism, 193, 221, 231, 272, 273, 
274, 280, 285, 288, 4.58, 460, 536, 
589 

Rickets, 374 

Rodent ulcer of the cornea, 177 ; of 
the eyelid, 213 



Saemisch's ulcer, 174 

Sarcoma of the choroid, 308, 310, 312, 
314 ; of the ciliary body, 302 ; of 
the conjunctiva, 149 ; of the cornea, 
202 ; of the eyelid, 220 ; of the 
iris, 294; of the sclerotic, 277 

Scarlatina, 107, 187, 462, 514, 587 

Scintillating scotoma, 511 

Scleritis, 193, 271, 274 

Sclerochoroiditis, posterior, 307 

Sclerosis, multiple, 336, 461, 465, 492, 
544, 585 ; diffuse, of the brain, 493 

Sclerotic, diseases of the, 271 ; pig- 
ment spots on, 277 ; injuries of the, 
276, 418, 450; ring, 100; tumors 
of the, 277 

Sclerotizing opacity of the cornea, 
193, 274 

Sclerotomy, 357 

Scopolamin, 287 (foot-note), 332 

Scorbutus, 514 

Scotoma, central, 157, 305, 463, 470, 
474, 492, 514; paracentric, 463; 
pericentric, 463 ; positive, 303, 416, 
427, 433, 437, 443 ', relative, 433, 
463 ; scintillating, 511 

Septicemia, 285, 434 

Seventh nerve, paralysis of the, 230 

Shadow-test, the, 90 

Short sight, 45 

Shot-silk retina, loi 

Siderosis, 209 

Sight, the sense of, 26 



628 



INDEX. 



Sixth nerve, paralysis of the, 500, 528, 

551 

Skull, fracture of the, 147, 258, 468, 
472,484,495, 552 

Small-pox, 107, 137, 187, 285 

Snellen's test-types, 31 

Snow-blindness, 444 

Spectacles in accommodative astheno- 
pia, 45; in albinism, 313; in ani- 
sometropia, 70; in aphakia, 41 1 ; in 
astigmatism, 63 ; in conic cornea, 
200 ; in convergent strabismus, 568, 
578; in cramp of accommodation, 
45 ; in hypermetropia, 45 ; in incipi- 
ent cataract, 369 ; in insufficiency of 
the internal recti, 583 ; in iridere- 
mia, 296; in myopia, 52; in nebu- 
lous cornea, 205 ; in paralysis of ac- 
commodation, 76 ; in paralysis of 
orbital muscles, 538 ; in presbyopia, 

n 

Sphenoid bone, fracture of the, 484 ; 
fissure, lesion at the, 524, 537 ; peri- 
ostitis at the, 75 

Spinal amaurosis, 468 ; cord, dis- 
eases of the, 334, 335, 336, 337, 
461, 468, 499 ; injuries of the, 503 ; 
miosis, T,T,^ 

Spring catarrh, ill 

Squint [see Strabismus) 

Staphyloma, anterior, 230, 274, 347 ; 
of the cornea, 118, 133, 142, 172; 
posterior, 51, 307 

Stenopeic spectacles, 200, 205, 313, 
370, 374 

Stomach, hemorrhage from the, 472 

Strabismus, 523 ; convergent concomi- 
tant, 45, 553 ; advancement of in- 
ternal rectus in, 576 ; amblyopia in, 
559 > angle of, 565; clinical varie- 
ties of, 561 ; dangers of operation 
for, 578 ; hypermetropia in, 45, 
555j 5^^j 579 5 measurement of, 
561 ; mobility of eye in, 567 ; opera- 
tion for, 570, 573 ; orthoptic treat- 
ment of, 568, 579; single vision 
in, 558; tenotomy in, 573, 584; 
apparent, 25, 524; apparent con- 
vergent, 49 ; apparent divergent, 42 ; 
divergent concomitant, 579 ; treat- 
ment of, 583 

Strumous ophthalmia, 153 

Stye, 217 

Symblepharon, 137, 152, 231 

Sympathetic irritation, 315, 513 ; oph- 



thalmitis, 191, 193, 197, 276, 283, 
292, 301, 306, 314, 419 

Synchysis, 417 ; scintillans, 418 

Synechia, anterior, 133, 172, 292, 361; 
posterior, 279, 284, 285, 360 

Syphilis, 75, 140, 148, 190, 193, 211, 
212, 221, 263, 272, 274, 278, 281, 
283, 285, 292, 304, 305, 307, 414, 
426, 429, 436, 442, 456, 459, 483, 
488, 536, 552 ; of the conjunctiva, 
148; of the eyelids, 211, 212; in- 
herited, 190, 274, 285, 304, 307, 
426, 436, 442 

Syphilitic choroidoretinitis, 304, 426 ; 
iritis, 281, 283, 285, 292, 426, 468 

Syringomyelia, 502 (foot-note) 



Tabes Dorsalis, 334, 336, 2,2,1, 499, 
506, 543, 544 

Tarsorrhaphy, 229, 231, 250, 609 

Tarsus, fatty degeneration of the, 1 16 ; 
tumor, 217 

Tattooing the cornea, 206 

Teeth, diseases of the, 587 ; Hutchin- 
son's, 190 

Temporosphenoid lobe, lesion of the, 
488 

Tension of the eyeball, 132, 133, t,t,^ 

Test-types, 31 

Third nerve, paralysis of the, 74, 75, 
221, 500, 533, 536, 547 

Toxic amblyopia, 30 

Trachoma, III, I13, I15, 123, 139, 
143, 179,231,235,243 

Transplantation of conjunctiva, 233 ; 
of cornea, 207 ; of skin, 257 

Trial-lenses, numbering of the, 17 

Trichiasis, 117, 215, 235 

Tubercle of the brain, 456, 488 ; of 
the choroid, 294, 312, 447 ; of the 
conjunctiva, 139, 212 ; of the cor- 
nea, 190 ; of the iris, 285, 293 

Tubercular meningitis, t,2)?), 457 

Tuberculosis, acute miliary, 312 ; 
chronic, 312 

Typhoid fever, 183, 285, 462, 587 



Upright ophthalmoscopic image, 79 

Uremia, 430, 431, 514 

Uremic amblyopia, 514 

Uric acid in the conjunctiva, 15 1 

Uterine hemorrhage, 472 

Uveal tract, diseases of the, 278 



INDEX. 



629 



Vaccine vesicles on the eyelids, 212 

Vessel, cilioretinal, 104 

Vision, acuteness of, 30 ; binocular, 
569, 570 (foot-note), 579, 579 (foot- 
note) ; central, t,t, ; defects of, which 
disqualify for the army, 613 ; for the 
Army Medical Department, 613 ; for 
the British Mercantile Service, 616 ; 
for the Home Civil Service, 614 ; 
for the Indian Civil Service, 614 ; 
for the Indian Marine Service, 615 ; 
for the Indian Medical Service, 614 ; 
for the Navy, 614 ; for the Royal 
Irish Constabulary, 615 ; eccentric, 
33 ; field of, T,T, ; field of, in glau- 
coma, 344; nulle, 485, 486 

Visual angle, the, 31 ; aphasia, 488, 
489 ; center, 477 ; center, lesion at 
the, 484 ; line, 25 ; memory, 489 ; 
subsenses, 26 

Vitreous humor, cholesterin in the, 
418 ; cysticercus in the, 422 ; de- 
tachment of the, 423 ; diseases of 
the, 375, 414, 450; fluidity of the, 
415, 417; foreign bodies in the, | 
418 ; hemorrhage in the, 275, Tfj^, 
415, 424, 432, 433» 437,438; in- 



flammatory processes in the, 414, 
419; muscse volitantes of the, 417 ; 
opacities in the, 51, 139, 274, 280, 
285, 299, 415, 426; persistent hya- 
loid artery in the, 423 ; purulent in- 
flammation of the, 306, 414, 419 ; 
vessels in the, 423 



Wernicke's pupil-symptom, 487 
Whooping-cough, 147, 183, 307 
Word-blindness, 487, 488 



Xanthelasma of the eyelids, 219 
Xerophthalmia, 137, 142, 513; with 
ulceration of cornea, 144, 180, 513 



Young-Helmholtz theory of the 
color-sense, 28 



Zonula of Zinn, change of, in accom- 
modation, 20 
Zonular cataract, 373, 406 



CARD EXPLANATOEY OF HOLMGEEN'S TESTS 
FOE COLOUE BLINDNESS. 

Test I. 



Confusion Colours. 




f 



Test II. a. 



Eed Blindness. 



Green Blindness. 





Test II. h. 



Eed Blindness. 



Green Blindness, 



10 



11 



12 



13 





N.B. — This Card is merely intended to illustrate the text {The Colour 
Sense, Chap. I. and Appendix I.), and not itself for use as a test. 



